Harmful or Beneficial?


By Saad Anjum


In 2011, the Accreditation Council for Graduate Medical Education (ACGME) lowered the maximum shift of thirty consecutive hours to sixteen for first year medical residents. Sandra Boodman, writing in Kaiser Health News, highlights several studies that question ACGME’s decision and its consequences.


One study—done here at Johns Hopkins by Sanjay Desai MD—randomly assigned interns to either a 2003-compliant model or a 2011-compliant model for duty hours and supervision. The results suggest that 2011-compliant shorter shifts allowed for more sleep, but interns attended fewer educational programs, patient handoffs occurred more often and interns perceived that they were providing a lower quality of treatment than the interns who worked 2003-compliant shifts.


Published alongside this study, University of Michigan’s Srijan Sen, an assistant professor of psychiatry, used results from the Intern Health Study, an ongoing longitudinal study, to compare responses from first-year interns serving before (2009, 2010) and after (2011) the implementation of the 2011 regulations. Results here showed that the post-regulation change group had a small actual decrease in the number of duty hours reported, no change in sleep or depressive symptoms, and a surprising increase in the number of self-reported concerns about making serious medical errors.


Both studies raise concerns about the possibility of the regulation change resulting in unintended harms and whether the change is achieving its intended goals. Matthew DeCamp, MD, PhD, Assistant Professor at the Johns Hopkins Berman Institute of Bioethics, weighs in on the results of these studies by raising a few key themes and reflecting on his own experience as an intern.


DeCamp’s initial response is that the studies present interesting preliminary data that warrants further exploration. The first theme he raises is that of hard outcomes versus soft outcomes. Hard outcomes relate to observed or identifiable events, whereas soft outcomes relate to individual’s perceptions of whether an event occurred. “Most notably, these studies rely a lot on perceived outcomes, self report—not hard outcomes,” DeCamp explains, stressing that the data warrants further exploration before a verdict can be reached. Perceived safety problems under the new system, DeCamp says, are warning signs that require further exploration and studies with hard outcomes.


Another theme DeCamp raises is that of complex systems. Consider a wristwatch, where changing just one gear may be difficult when attempting to keep the overall system of the watch intact. DeCamp says, “If you change the residents’ workflow, but the rest of the hospital has been based on a prior system, it’s not surprising that people might perceive the new system as inadequate. This could be because of the change but also in part because hospitals are complex.” Note: workflow is the sequence of processes through which work passes from start to completion. DeCamp explains that the new system may need time to adapt to the changes before it can be properly measured for consequences—good or bad.


On the note of individual systems adapting to the regulation, DeCamp raises his third theme: context. He states, “The context in which the change occurs could really matter. Certain program structures might be more amenable to the regulation changes than others.”


In some cases, this might only become apparent over time, raising the question of whether studies should examine changes over months or years to see how systems adapt.


Adaptation also applies to specific changes, such as handoffs.  “We don’t really know whether three handoffs is better than seven handoffs because part of it depends on how good the handoffs are. It could be that over time, residents—if given adequate training—get better at handoffs.” There are transition periods over time when the systems could adapt and improve under the new regulations, something that further studies could explore in an attempt to investigate the consequences of the new regulations.


DeCamp trained as an internal medicine intern at the University of Michigan with an eighty-hour workweek and thirty-hour shifts and was able to see the effects of the regulation changes even though he left a year before they were enforced, “The program instituted changes even the year before the rules were going to take effect, to make sure they could hit the ground running.” In this context, the residency program maintained a long transition period in which they tested different schedules before finalizing their method of going forward. Each residency program had a different way with adapting, DeCamp comments.


Having gone through a system with thirty-hour shifts, DeCamp did feel that the system had benefits, such as, “seeing a patient over thirty hours, particularly the night of admission. That’s often a critical period in a patient’s clinical course.” However, he stresses the need measure the actual consequences with further studies, “What we need are studies to examine whether, on balance, losing that benefit [seeing a patient over thirty hours] is compensated for by other benefits like patient safety, or resident quality of life, or any of these other factors.”


Saad Anjum is a undergraduate bioethics intern at the Johns Hopkins Berman Institute of Bioethics and a writing seminars major at Johns Hopkins University

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Matthew DeCamp
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