Editorials

Last 50 Editorials

(Click on title to be directed to editorial, most recent listed first)

EMR Fines Test Trump Administration’s Opposition to Bureaucracy
Breaking the Guidelines for Better Care
Worst Places to Practice Medicine
Pain Scales and the Opioid Crisis
In Defense of Eminence-Based Medicine
Screening for Obstructive Sleep Apnea in the Transportation Industry—
   The Time is Now
Mitigating the “Life-Sucking” Power of the Electronic Health Record
Has the VA Become a White Elephant?
The Most Influential People in Healthcare
Remembering the 100,000 Lives Campaign
The Evil That Men Do-An Open Letter to President Obama
Using the EMR for Better Patient Care
State of the VA
Kaiser Plans to Open "New" Medical School
CMS Penalizes 758 Hospitals For Safety Incidents
Honoring Our Nation's Veterans
Capture Market Share, Raise Prices
Guns and Sleep
Is It Time for a National Tort Reform?
Time for the VA to Clean Up Its Act
Eliminating Mistakes In Managing Coccidioidomycosis
A Tale of Two News Reports
The Hands of a Healer
The Fabulous Fours! Annual Report from the Editor
A Veterans Day Editorial: Change at the VA?
A Failure of Oversight at the VA
IOM Releases Report on Graduate Medical Education
Mild Obstructive Sleep Apnea: Beyond the AHI
Multidisciplinary Discussion (MDD) in Interstitial Lung Disease; Some
   Reflections
VA Administrators Breathe a Sigh of Relief
VA Scandal Widens
Don’t Fire Sharon Helman-At Least Not Yet
Questioning the Inspectors
Qualitygate: The Quality Movement's First Scandal
What's Wrong with Expert Opinion?
The Tremendous Threes! Annual Report from the Editor
Obamacare and Computers-Who Is to Blame? 
HIPAA-Protecting Patient Confidentiality or Covering Something Else?
Are Medical Guidelines Better Than Flipping a Coin?
Who Will Benefit and Who Will Lose from Obamacare?
Smoking, Epidemiology and E-Cigarettes
Treatment after a COPD Exacerbation
Executive Pay and the High Cost of Healthcare
Choosing Wisely-Where Is the Choice?
The State of Pulmonary and Critical Care in the Southwest
Doxycycline and IL-8 Modulation in a Line of Human Alveolar 
   Epithelium: More Evidence for the Anti-Inflammatory Function 
   of Some Antimicrobials
What to Expect from Obamacare
The Terrific Twos! Annual Report from the Editor
Maintaining Medical Competence

 

For complete editorial listings click here.

The Southwest Journal of Pulmonary and Critical Care publishes editorials related to manuscripts in the Journal as well as areas of interest to the pulmonary, critical care and sleep communities. In general, editorials are written by the editors or are invited. However, the Journal will consider editorials written by others. Before submitting, a potential author of the editorial should contact the editor.

-------------------------------------------------------------------------------------

Saturday
Jun172017

EMR Fines Test Trump Administration’s Opposition to Bureaucracy

Earlier this week the Health and Human Services Office of Inspector General (OIG) released an audit report on $6.1 billion paid to 250,000 clinicians in the incentive program for meaningful use of electronic medical records (EMRs) (1). A random sample of 100 clinicians who had received at least one incentive payment revealed that 14 of them who had had not met all meaningful use requirements as they had attested (Table 1) (1,2).

Table 1. Meaningful use deficiencies identified in 14 of 100 clinicians.

  • Six clinicians couldn't provide a mandatory analysis of security risks;
  • Four clinicians couldn't prove that they had generated at least one list of patients-another requirement -who had the same condition;
  • Three clinicians could not provide patient encounter data to document that they had met various meaningful use measures;
  • One clinician had 90-days' worth of patient encounter data when a year's worth was needed;
  • One clinician did not use certified EHR technology as much as required.

The OIG recommended that the Center for Medicare and Medicaid Services recover the $291,222 paid to the clinicians in the sample group and extrapolated the recovery to $729 million from the remaining clinicians based on this random sample. This is about 13% of the incentives paid to clinicians for the CMS EMR program. The decision to carry out the recommendation will ultimately fall to a US Department of Health and Human Services (HHS) secretary, Tom Price MD, who has opposed government programs that created regulatory hassles for physicians.

"We would protest if they went through with this," said Robert Tennant, director of health information technology policy at the Medical Group Management Association (MGMA). "Going after folks who tried to meet arbitrary government requirements, who made a good faith effort, isn't fair” (2). Tennant said that this complexity, made worse by evolving requirements, helps explain the deficiencies listed in the OIG audit. "I'm not surprised some providers found it daunting to keep up with the changes," he said. The requirement for a security risk analysis is a problem, Tennant noted, because CMS hasn't given clinicians sufficient guidance on how to meet the requirements. "This is a real stumbling block for smaller practices," he said. "They're not security experts, they're clinicians" (2). American College of Physicians Vice President of Governmental Affairs and Medical Practice Shari Erickson said that clinicians who originally attested to meaningful use lacked clear, specific guidance on what documentation they needed for each requirement (2).

CMS incentivized using EMRs because many clinicians were reluctant to initiate EMRs in their practices because of cost and efficiency considerations. Average costs to initiate an EMR were $163r,765 for a single practitioner and $233,298 for a practice with five physicians (3). Reimbursement under the EMR program was about $65,000 per provider (4). Furthermore, there was an 8% decrease in productivity after EMR initiation (3). In other words, if physicians wanted to see Medicare/Medicaid patients they were asked to use EMRs that cost them money and made them work harder.

The violations identified in the OIG audit seem fairly minor and are the type of trivial violations that the lawyers and bureaucrats seem to delight in identifying and excessively penalizing clinicians. In contrast, large health care organizations seem to go unpunished for more egregious violations. Witness the lack of action against Banner Healthcare for compromising 3.7 million medical records in 2016 (5). The average cost of data breach has been estimated at $398 per compromised record (2). Extrapolating, Banner should be fined nearly $1.5 billion.

Medicine is likely the most regulated industry in the US. Several of my colleagues have complained that the regulation seems more directed at them and not at the hospitals and insurance companies that seem to create most of the increase in cost and the violations. Some of the more paranoid clinicians viewed the EMR as nothing more than a tactic to gain further control of their practice and viewed Hillary Clinton as someone who would continue the onslaught on clinicians. These fines for EMR noncompliance are the first true test for the Trump administration in the area of healthcare regulation. Many of my colleagues are watching Trump and Price to see if their opposition to bureaucracy was merely lip service or has some backbone. 

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Levinson DR. Medicare paid hundreds of millions in electronic health record incentive payments that did not comply with federal requirements. Department of Health and Human Services. Office of the Inspector General. June 2017. Available at: https://oig.hhs.gov/oas/reports/region5/51400047.pdf (accessed 6/15/17).
  2. Lowes R. Proposal to take back EHR bonuses galls med societies. Medscape. June 13, 2017. Available at: http://www.medscape.com/viewarticle/881563?nlid=115819_4502&src=wnl_dne_170615_mscpedit&uac=9273DT&impID=1368453&faf=1 (accessed 6/15/17). 6
  3. Fleming NS, Aponte P, Ballard DJ, Becker E, Collinsworth A, Culler S, Kudyakov R, McCorkle R, Chang D. Exploring financial and non-financial costs and benefits of health information technology: the impact of an ambulatory electronic health record on financial and workflow in primary care practices and costs of implementation. The Agency for Healthcare Research and Quality (AHRQ). 2011. Available at: https://healthit.ahrq.gov/sites/default/files/docs/publication/R03HS018220-01Flemingfinalreport2011.pdf (accessed 6/15/17).
  4. Hayes TO. Are electronic medical records worth the costs of implementation?American Action Forum. August 6, 2015. Available at: https://www.americanactionforum.org/research/are-electronic-medical-records-worth-the-costs-of-implementation/ (accessed 6/15/17).
  5. Robbins RA. Banner hacked-3.7 million at risk. Southwest J Pulm Crit Care. 2016;13(2):80-1. [CrossRef]

Cite as: Robbins RA. EMR fines test Trump administration's opposition to bureaucracy. Southwest J Pulm Crit Care. 2017;14(6):312-4. doi: https://doi.org/10.13175/swjpcc079-17 PDF

Saturday
Jun102017

Breaking the Guidelines for Better Care

Two events happened this past week that inspired this editorial. First, on Wednesday morning I read the editorial titled “Breaking the Rules for Better Care” by Don Berwick et al. in JAMA (1). Berwick reports a survey of about 40 hospitals done by The Institute of Healthcare Improvement (IHI). The survey asked the question “If you could break or change any rule in service of a better care experience for patients or staff, what would it be?”. The answers were not surprising. Most centered on annoying hospital rules such as visiting hours, not waking patients, correct HIPPA interpretation, and eliminating the 3-day rule. Although these are correct, in the whole they have minimal effect on healthcare. Other suggestions more likely to improve patient care included improving access, reducing wait times and earlier patient mobility. From the suggestions, it seems likely that most were from administrators. In the editorial Berwick decried “Habits embedded in organizational behaviors, based on misinterpretations and with little to no actual foundation in legal, regulatory, or administrative requirements”. He goes on to say, “Health care leaders may be well advised to ask their clinicians, staffs, and patients which habits and rules appear to be harming care without commensurate benefits and, with prudence and circumspection, to change them.” As a clinician, I thoroughly agree with both of Berwick’s points.

Later that afternoon, I listened to a lecture by Clement Singarajah on sepsis guidelines. He reviewed the severe sepsis bundles promoted by the Surviving Sepsis Campaign and IHI, the latter being Berwick’s organization who wrote the editorial noted above (Table 1) (2,3).

Table 1.  Severe Sepsis Bundles.

The Severe Sepsis 3-Hour Resuscitation Bundle contains the following elements, to be completed within 3 hours of the time of presentation with severe sepsis:

  • Measure Lactate Level
  • Obtain Blood Cultures Prior to Administration of Antibiotics
  • Administer Broad Spectrum Antibiotics
  • Administer 30 mL/kg Crystalloid for Hypotension or Lactate ≥4 mmol/L

The 6-Hour Septic Shock Bundle contains the following elements, to be completed within 6 hours of the time of presentation with severe sepsis:

  • Apply Vasopressors (for Hypotension That Does Not Respond to Initial Fluid Resuscitation to Maintain a Mean Arterial Pressure (MAP) ≥65 mm Hg)
  • In the Event of Persistent Arterial Hypotension Despite Volume Resuscitation (Septic Shock) or Initial Lactate ≥4 mmol/L (36 mg/dL):
    • Measure Central Venous Pressure (CVP)
    • Measure Central Venous Oxygen Saturation (ScvO2)
  • Remeasure Lactate If Initial Lactate Was Elevated

We carefully reviewed each of the metrics, and concluded most were non-evidence based, outdated, or contradicted by more recent and better trials. The only exception was early antibiotic administration. Most of us reaffirmed our belief in the germ theory and felt that early administration of the correct antibiotics was probably mostly evidence-based and reasonable (4).

Is it possible that most of the metrics in the bundle are merely a waste of time as we concluded or could some be harmful? First, a recent meta-analysis examined a conservative fluid strategy in sepsis compared with a liberal strategy (the goal-directed therapy as advocated by the sepsis bundles) (5). Although there was no change in mortality, a conservative strategy resulted in increased ventilator-free days and reduced length of ICU stay. The meta-analysis concluded that the studies were underpowered to show a mortality benefit. Second, most of us had experienced delays in initiating antibiotics, the only guideline that makes a difference, while waiting for blood cultures to be drawn. None of us knew data that drawing blood cultures makes a difference in patient outcomes.

Berwick recommended asking clinicians which rules may be harming care. Rather than chiding others to do something, a good place to start might be IHI’s sepsis guidelines. The issue of continued support for non-evidence based or outdated guidelines points out the rigid dichotomy between self-delusional beliefs and science. Many (some would say most) guidelines are based on opinions and not science (6). Healthcare would be better if groups such as the Surviving Sepsis Campaign, IHI and the Centers for Medicare and Medicaid Services would follow their own advice and not burden healthcare providers with non-evidence based guidelines. Instead, they should only issue guidelines after carefully conducted, randomized, controlled trials establish a guideline rather than mandating the self-delusional beliefs of a few.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Berwick DM, Loehrer S, Gunther-Murphy C. Breaking the rules for better care. JAMA. 2017 Jun 6;317(21):2161-2. [CrossRef] [PubMed]
  2. Surviving Sepsis Campaign. Updated bundles in response to new evidence. Available at: http://www.survivingsepsis.org/SiteCollectionDocuments/SSC_Bundle.pdf (accessed 6/9/17).
  3. Institute for Healthcare Improvement. Severe sepsis bundles. Available at: http://www.ihi.org/resources/Pages/Tools/SevereSepsisBundles.aspx (accessed 6/9/17).
  4. Seymour CW, Gesten F, Prescott HC, et al. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med. 2017 Jun 8;376(23):2235-44. [CrossRef] [PubMed]
  5. Silversides JA, Major E, Ferguson AJ, et al. Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis. Intensive Care Med. 2017 Feb;43(2):155-170. [CrossRef] [PubMed]
  6. Lee DH, Vielemeyer O. Analysis of overall level of evidence behind Infectious Diseases Society of America practice guidelines. Arch Intern Med. 2011;171:18-22. [CrossRef] [PubMed] 

Cite as: Robbins RA. Breaking the guidelines for better care. Southwest J Pulm Crit Care. 2017;14(6): 285-7. doi: https://doi.org/10.13175/swjpcc072-17 PDF

Saturday
Jun102017

Breaking the Guidelines for Better Care

Two events happened this past week that inspired this editorial. First, on Wednesday morning I read the editorial titled “Breaking the Rules for Better Care” by Don Berwick et al. in JAMA (1). Berwick reports a survey of about 40 hospitals done by The Institute of Healthcare Improvement (IHI). The survey asked the question “If you could break or change any rule in service of a better care experience for patients or staff, what would it be?”. The answers were not surprising. Most centered on annoying hospital rules such as visiting hours, not waking patients, correct HIPPA interpretation, and eliminating the 3-day rule. Although these are correct, in the whole they have minimal effect on healthcare. Other suggestions more likely to improve patient care included improving access, reducing wait times and earlier patient mobility. From the suggestions, it seems likely that most were from administrators. In the editorial Berwick decried, “Habits embedded in organizational behaviors, based on misinterpretations and with little to no actual foundation in legal, regulatory, or administrative requirements”. He goes on to say, “Health care leaders may be well advised to ask their clinicians, staffs, and patients which habits and rules appear to be harming care without commensurate benefits and, with prudence and circumspection, to change them.” As a clinician, I thoroughly agree with both of Berwick’s points.

Later that afternoon, I listened to a lecture by Clement Singarajah on sepsis guidelines. He reviewed the severe sepsis bundles promoted by the Surviving Sepsis Campaign and IHI, the latter being Berwick’s organization who wrote the editorial noted above (Table 1) (2,3).

Table 1.  Severe Sepsis Bundles.

The Severe Sepsis 3-Hour Resuscitation Bundle contains the following elements, to be completed within 3 hours of the time of presentation with severe sepsis:

  • Measure Lactate Level
  • Obtain Blood Cultures Prior to Administration of Antibiotics
  • Administer Broad Spectrum Antibiotics
  • Administer 30 mL/kg Crystalloid for Hypotension or Lactate ≥4 mmol/L

The 6-Hour Septic Shock Bundle contains the following elements, to be completed within 6 hours of the time of presentation with severe sepsis:

  • Apply Vasopressors (for Hypotension That Does Not Respond to Initial Fluid Resuscitation to Maintain a Mean Arterial Pressure (MAP) ≥65 mm Hg)
  • In the Event of Persistent Arterial Hypotension Despite Volume Resuscitation (Septic Shock) or Initial Lactate ≥4 mmol/L (36 mg/dL):
    • Measure Central Venous Pressure (CVP)
    • Measure Central Venous Oxygen Saturation (ScvO2)
  • Remeasure Lactate If Initial Lactate Was Elevated

We carefully reviewed each of the metrics, and concluded most were non-evidence based, outdated, or contradicted by more recent and better trials. The only exception was early antibiotic administration. Most of us reaffirmed our belief in the germ theory and felt that early administration of the correct antibiotics was probably mostly evidence-based and reasonable (4).

Is it possible that most of the metrics in the bundle are merely a waste of time as we concluded or could some be harmful? First, a recent meta-analysis examined a conservative fluid strategy in sepsis compared with a liberal strategy (the goal-directed therapy as advocated by the sepsis bundles) (5). Although there was no change in mortality, a conservative strategy resulted in increased ventilator-free days and reduced length of ICU stay. The meta-analysis concluded that the studies were underpowered to show a mortality benefit. Second, most of us had experienced delays in initiating antibiotics, the only guideline that makes a difference, while waiting for blood cultures to be drawn. None of us knew data that drawing blood cultures makes a difference in patient outcomes.

Berwick recommended asking clinicians which rules may be harming care. Rather than chiding others to do something, a good place to start might be IHI’s sepsis guidelines. The issue of continued support for non-evidence based or outdated guidelines points out the rigid dichotomy between self-delusional beliefs and science. Many (some would say most) guidelines are based on opinions and not science (6). Healthcare would be better if groups such as the Surviving Sepsis Campaign, IHI and the Centers for Medicare and Medicaid Services would follow their own advice and not burden healthcare providers with non-evidence based guidelines. Instead, they should only issue guidelines after carefully conducted, randomized, controlled trials establish a guideline rather than mandating the self-delusional beliefs of a few.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Berwick DM, Loehrer S, Gunther-Murphy C. Breaking the rules for better care. JAMA. 2017 Jun 6;317(21):2161-2. [CrossRef] [PubMed]
  2. Surviving Sepsis Campaign. Updated bundles in response to new evidence. Available at: http://www.survivingsepsis.org/SiteCollectionDocuments/SSC_Bundle.pdf (accessed 6/9/17).
  3. Institute for Healthcare Improvement. Severe sepsis bundles. Available at: http://www.ihi.org/resources/Pages/Tools/SevereSepsisBundles.aspx (accessed 6/9/17).
  4. Seymour CW, Gesten F, Prescott HC, et al. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med. 2017 Jun 8;376(23):2235-44. [CrossRef] [PubMed]
  5. Silversides JA, Major E, Ferguson AJ, et al. Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis. Intensive Care Med. 2017 Feb;43(2):155-170. [CrossRef] [PubMed]
  6. Lee DH, Vielemeyer O. Analysis of overall level of evidence behind Infectious Diseases Society of America practice guidelines. Arch Intern Med. 2011;171:18-22. [CrossRef] [PubMed]

Cite as: Robbins RA. Breaking the guidelines for better care. Southwest J Pulm Crit Care. 2017;14(6):285-7. doi: https://doi.org/10.13175/swjpcc072-17 PDF

Tuesday
May162017

Worst Places to Practice Medicine

Medscape periodically publishes a “Best” and “Worst” places to practice medicine (1). We were struck by this year’s list because three of the five worst places to practice medicine are in the Southwest (Table 1).

Table 1. Medscape’s “worst” places to practice medicine.

  1. New Orleans, Louisiana
  2. Phoenix, Arizona
  3. Las Vegas, Nevada
  4. Albuquerque, New Mexico
  5. Tulsa, Oklahoma

While Minneapolis rated the best place to practice, only 2 cities from the Southwest made the top 25 “Best” list-Salt Lake City at 13th and Colorado Springs at 24th. Most of the top 25 are from the Midwest or Northeast. None from California made the best places list and only the only Southern location was Virginia Beach, Virginia. 

Rankings resulted from the combination of twelve 50-state rankings: medical board actions per doctor; malpractice lawsuits per doctor; office-based primary care physicians per population; physician income; employer-based insurance rate per population; insurance coverage per population; reported rates of well-being of the general population; violent crime rates; participation in wildlife-related recreation; divorce rates; use of family-friendly amenities; and cost of living.

Phoenix, Las Vegas and Albuquerque were singled out for high rates of uninsured patients. Phoenix was also singled out for its moderately high malpractice suit rate.

Before everyone in the Southwest decides to move, these ratings may be meaningless, much like hospital rankings (2). Furthermore, there seems little that physicians can do to improve the situation based on the selected metrics. What can be done is to continue our efforts through our professional organizations to educate the public and their elected representatives that job satisfaction is necessary to recruit and retain physicians, as well as nurses and other health care professionals. A healthcare organization without these well-educated and caring people lacks quality and attempts to substitute substandard care is much like trying to substitute a Yugo for a Mercedes.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Page L. Best places to practice to avoid burnout. Medscape. May 10, 2017. Available at: http://www.medscape.com/viewarticle/879573 (accessed 5/16/17).
  2. Robbins RA, Gerkin RD. A comparison between hospital rankings and outcomes data. Southwest J Pulm Crit Care. 2013;7(3):196-203. [CrossRef] 

Cite as: Robbins RA. Worst places to practice medicine. Southwest J Pulm Crit Care. 2017;14(5):236-7. doi: https://doi.org/10.13175/swjpcc060-17 PDF 

Monday
Apr032017

Interns Shall Not Sleep: The Duty Hours Boomerang

On March 10, 2017, the Accreditation Council for Graduate Medical Education (ACGME) announced revisions to its common program requirements related to duty hours (1). Effective on July 1, 2017, the most important change will be an increase in the maximum consecutive hours that an intern may work. Interns will now be able to continuously perform patient care work up to a maximum of 24 hours with an additional 4 hours for managing care transitions. This reverses the controversial reduction to 16 hours that occurred in 2011 (2).

The regulation of house staff duty hours formally began in the late 1980s. It was precipitated largely because of the publicity resulting from the 1984 death of Libby Zion in a New York teaching hospital that was attributed partly to poor decisions made by fatigued and overworked house staff (3). Consequently, the state of New York in 1989 passed laws restricting the maximum number of hours that house staff could work to 80 hours/week, a minimum of 8 hours between shifts and 1 day off per week (3). Before 1987, duty hours for house staff were largely unregulated and governed only by the requirement that “Hospital duties should not be so pressing or consuming that they preclude ample time for other important phases of the training program or for personal needs.”(4) Consequently, in some training programs, every other night call was mandated and in a few, residents were required to live in the hospital (hence, the historical origin of the term, “resident”). Some change occurred in 1987 when the ACGME mandated 1 day off per week and call no more frequently than every third night (4). However, it was not until 2003 that the ACGME common program requirements were revised to restrict duty hours to 80 hours per week and a maximum of 24 hours of continuous duty with an additional 6 hours allowed for care transitions and educational activities (4). These requirements remained in effect until 2011. At that time, in response to an Institute of Medicine report recommending a maximum work shift for all residents of 16 hours (5,6), and research demonstrating that interns working 24 hour shifts in comparison to 16 hours shifts made more attentional and serious medical errors (7,8), the ACGME reduced the maximum shift length for only interns to 16 hours (2). It was felt that interns would be more susceptible to the impact of sleep deprivation and this would allow them to better focus on educational activities.

The limitation on interns not working more than 16 hours per day was met by several concerns from training programs, faculty and house staff themselves (9). Perhaps the most important was the issue of “hand-offs”. An inevitable consequence of reducing intern shift length was the more frequent need to transition care from one house officer to another. It was suggested that increased fragmentation of care and failure to transmit important patient care information would result. Thus, it was suggested that the potential improvement in patient safety from non sleep deprived interns would be offset by the detrimental impact of more frequent handoffs. Perhaps equally important was the argument that the educational experience of better continuity of care would be lost. This was thought to be especially important for surgical training programs where post-operative issues often occur at night. Logistical issues also were highlighted. In most cases, a 16 hour work schedule for interns necessitated a “night float” system, thought by most training programs to be a non-educational experience. Additionally, in some programs, loss of intern coverage meant greater work for senior residents and faculty. Many residents and interns themselves were not in favor of the change because of perceived loss of educational experience and scheduling issues. Finally, the economic cost was not trivial with one estimate of an additional $1.6 billion per year cost (10).

Why the change back to a maximum of 24 hour shifts? Since 2011, a number of studies have been published evaluating the impact of restricting shift length to 16 hours or less. In a 2015 systematic review of 27 studies published between 2010 and 2014, the authors concluded that the restriction in duty hours did not improve patient care or house staff well-being, but did negatively impact house staff education (11). Of particular note was that “night float” in most studies was associated with decreased attendance at conferences, time spent with the attending physician and time doing independent reading. A particularly impactful study not included in the systematic review was the 2015 Flexibility in Duty Hour Requirements for Surgical Trainees Trial (FIRST) (12). The FIRST study was a randomized cluster trial of 118 general surgery residency programs in which programs were assigned to one of two groups, adherence to the 2011 ACGME duty requirements or a more flexible policy where some ACGME duty hour requirements could be waived. Specifically, the 16 hour duty limit for interns could be exceeded; duty shifts could be longer than 28 hours; time between shifts could be less than 8 hours; and time off after more than 24 hours of continuous duty could be less than 14 hours. The study found that programs in the flexible policy arm did not experience worse patient outcomes (e.g., death or serious complications) and there were no differences in residents’ ratings of well-being and educational quality. As a consequence of the concerns raised as well as the aforementioned research findings, the ACGME convened a taskforce to review and recommend changes to its common program requirements including duty hours. The result was to increase the duty hours for interns back to 24 hours as well as additional focus on patient safety and physician well-being (1). The remaining requirements (e.g., maximum of 80 hours/week) were essentially unchanged. However, individual specialties could impose more restrictive regulations. For example, Internal Medicine specifies workload caps limiting the number of new admissions and overall number of patients that can be under the care of an intern or resident.

Is this a reversion to former standards a step forward or has the clock ticked backwards? Despite the seeming clarity in the ACGME requirements, the answer is uncertain. There has been considerable research that documents the detrimental effects of sleep deprivation on human physical and mental performance. The evidence that reaction time deteriorates rapidly after 16 hours of continuous wakefulness is not in dispute (13). Furthermore, it is well known that many house staff have chronic sleep debt and human performance is at its worse during the nighttime portion of the circadian cycle. In conjunction with at least 16 hours of continuous wakefulness, it is likely that many house staff are performance impaired. Why is this impairment not demonstrated in field studies? There is evidence that adverse effects related to sleep loss are variable among individuals and may involve a trait-like vulnerability. Additionally, the brain likely has a cognitive reserve which might allow some individuals to cope with the insult of sleep deprivation by using preexisting cognitive processes or by enlisting compensatory processes before performance is adversely affected (14). This may be especially true in those with high intelligence such as physicians. Therefore, on average, there may not be an identifiable impact of permitting shifts greater than 16 hours. However, an adverse patient care outcome can occur from a decision made by one sleep deprived intern. Given that there are strong opinions on both sides of the issue, targeted research is needed. One possibility would be to identify individuals at the extremes of vulnerability to sleep deprivation and then to determine the impact of varying shift lengths. Only with such information will the argument be put to “bed”.

Stuart F. Quan, M.D.

Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA

Asthma and Airways Research Center, University of Arizona College of Medicine, Tucson, AZ USA

References

  1. ACGME Releases Revised Common Program Requirements,Section VI. The Learning and Working Environment. March 10, 2017. Available at: http://www.acgme.org/Portals/0/PDFs/Nasca-Community/ACGME-Common-Press-Release-3-10-2017.pdf (accessed 4/3/17).
  2. Nasca TJ, Day SH, Amis ES Jr; ACGME Duty Hour Task Force. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010 Jul 8;363(2):e3. [CrossRef] [PubMed]
  3. Thorpe KE. House staff supervision and working hours. Implications of regulatory change in New York State. JAMA. 1990 Jun 20;263(23):3177-81. [CrossRef] [PubMed]
  4. Philibert I, Barach P. Residents' hours of work. BMJ. 2002 Nov 23;325(7374):1184-5. [CrossRef] [PubMed]
  5. Quan SF. Work hours during residency training--the IOM speaketh. J Clin Sleep Med. 2009 Feb 15;5(1):9-10. [PubMed]
  6. IOM (Institute of Medicine). 2009. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington, DC: The National Academies Press. Available at: http://www.nationalacademies.org/hmd/Reports/2008/Resident-Duty-Hours-Enhancing-Sleep-Supervision-and-Safety.aspx (accessed 4/3/17).
  7. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med. 2004 Oct 28;351(18):1838-48. [CrossRef] [PubMed]
  8. Lockley SW, Cronin JW, Evans EE, et al. Effect of reducing interns' weekly work hours on sleep and attentional failures. N Engl J Med. 2004 Oct 28;351(18):1829-37. [CrossRef] [PubMed]
  9. Antiel RM, Thompson SM, Hafferty FW, et al. Duty hour recommendations and implications for meeting the ACGME core competencies: views of residency directors. Mayo Clin Proc. 2011 Mar;86(3):185-91. [CrossRef] [PubMed]
  10. Nuckols TK, Bhattacharya J, Wolman DM, Ulmer C, Escarce JJ. Cost implications of reduced work hours and workloads for resident physicians. N Engl J Med. 2009 May 21;360(21):2202-15. [CrossRef] [PubMed]
  11. Bolster L, Rourke L. The Effect of Restricting Residents' Duty Hours on Patient Safety, Resident Well-Being, and Resident Education: An Updated Systematic Review. J Grad Med Educ. 2015 Sep;7(3):349-63. [CrossRef] [PubMed]
  12. Bilimoria KY, Chung JW, Hedges LV, et al. National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training. N Engl J Med. 2016 Feb 25;374(8):713-27. [CrossRef] [PubMed]
  13. Van Dongen HP, Baynard MD, Maislin G, Dinges DF. Systematic interindividual differences in neurobehavioral impairment from sleep loss: evidence of trait-like differential vulnerability. Sleep. 2004 May 1;27(3):423-33. [PubMed]
  14. Stern Y. Cognitive reserve. Neuropsychologia. 2009 Aug;47(10):2015-28. [CrossRef] [PubMed]

Cite as: Quan SF. Interns shall not sleep: the duty hours boomerang. Southwest J Pulm Crit Care. 2017;14(4):153-6. doi: https://doi.org/10.13175/swjpcc043-17 PDF