July 4, 2015
Regulations in the United States have limited the work hours that newly minted physicians, called interns, and physicians in training, called residents, can work in the hospital. The work hour restrictions were ushered in based on evidence that sleep deprived physicians make more errors (i.e. medication errors, diagnostic errors, serious errors with critically ill patients, etc.) and score lower on simple cognition tests including response time, reasoning, recall, and concentration.
However, inextricably tied to this reduction in the work hours for physicians in training is the need for more handoffs. If a doctor taking care of a given hospitalized patient can only work a set number of hours in each twenty-four hour period, then they must pass off the patient’s care to a colleague who then will carry the torch until they themselves hit their work hour limit. At that point, repeat! The patient must then be passed back to the original doctor or yet another doctor. This process, dubbed handoffs or signouts occurs at each shift change, which are also called transitions in care. However, the more frequently handoffs occur, the more important effective communication between providers becomes. Essentially the increased number of patient handoffs has brought the challenge of effective communication to the fore. How does one methodically and repeatedly communicate all of the important details about each patient they are covering in the hospital to the provider coming on duty? Many have likened this process to a game of telephone and we all know how that game plays out.
Interestingly, recent research from December 2014 published in the Journal of the American Medical Association found that reductions in the work hours for physicians in training did not lead to any statistically significant change in patient safety or the quality of patient care. The study endpoints the authors examined were all location thirty-day mortality and all cause hospital readmissions for Medicare patients with particular diagnoses. While all studies are limited and many are not broadly applicable or extendable to the general population, the good news is the authors did not report any statistically significant increases in mortality or readmissions (stroke patients did show a higher rate of readmission, OR 1.06, after the implementation of work hours, CI 1.001 to 1.13; though this finding was not conclusive and did not hold up in sensitivity analysis).
In all, the study suggests the work hour regulations may not be doing significant harm. So where does this leave us? Perhaps the benefit of better-rested doctors has been outweighed by the harm of more frequent signouts? Can we actually improve quality and reduce readmissions if we standardize handoffs and improve the effectiveness of the handoff game of telephone? Alas, the answers remain elusive and more research is needed as the pendulum continues to swing and the academic medicine establishment works to find the right equilibrium between the work hours for resident physicians and the impact of increased numbers of handoffs.
For more perspectives see the July 1, 2015 New York Times Op-Ed piece on this topic.