Why Is It So Difficult to Get Rid of Bad Guidelines?

Reference as: Robbins RA. Why is it so difficult to get rid of bad guidelines? Southwest J Pulm Crit Care 2011;3:141-3. (Click here for a PDF version of the editorial)

My colleagues and I recently published a manuscript in the Southwest Journal of Pulmonary and Critical Care examining compliance with the Joint Commission of Healthcare Organization (Joint Commission, JCAHO) guidelines (1). Compliance with the Joint Commission’s acute myocardial infarction, congestive heart failure, pneumonia and surgical process of care measures had no correlation with traditional outcome measures including mortality rates, morbidity rates, length of stay and readmission rates. In other words, increased compliance with the guidelines was ineffectual at improving patient centered outcomes. Most would agree that ineffectual outcomes are bad. The data was obtained from the Veterans Healthcare Administration Quality and Safety Report and included 485,774 acute medical/surgical discharges in 2009 (2). This data is similar to the Joint Commission’s own data published in 2005 which showed no correlation between guideline compliance and hospital mortality and a number of other publications which have failed to show a correlation with the Joint Commission’s guidelines and patient centered outcomes (3-8). As we pointed out in 2005, the lack of correlation is not surprising since several of the guidelines are not evidence based and improvement in performance has usually been because of increased compliance with these non-evidence based guidelines (1,9).

The above raises the question that if some of the guidelines are not evidence based, and do not seem to have any benefit for patients, why do they persist? We believe that many of the guidelines were formulated with the concept of being easy and cheap to measure and implement, and perhaps more importantly, easy to demonstrate an improvement in compliance. In other words, the guidelines are initiated more to create the perception of an improvement in healthcare, rather than an actual improvement. For example in the pneumonia guidelines, one of the performance measures which have markedly improved is administration of pneumococcal vaccine. Pneumococcal vaccine is easy and cheap to administer once every 5 years to adult patients, despite the evidence that it is ineffective (10). In contrast, it is probably not cheap and certainly not easy to improve pneumonia mortality rates, morbidity rates, length of stay and readmission rates.

To understand why these ineffectual guidelines persist, one needs to understand who benefits from guideline implementation and compliance. First, organizations which formulate the guidelines, such as the Joint Commission, benefit. Implementing a program that the Joint Commission can claim shows an improvement in healthcare is self-serving, but implementing a program which provides no benefit would be politically devastating. At a time when some hospitals are opting out of Joint Commission certification, and when the Joint Commission is under pressure from competing regulatory organizations, the Joint Commission needs to show their programs produce positive results.

Second, programs to ensure compliance with the guidelines directly employ an increasingly large number of personnel within a hospital. At the last VA hospital where I was employed, 26 full time personnel were employed in quality assurance. Since compliance with guidelines to a large extent accounts for their employment, the quality assurance nurses would seem to have little incentive to question whether these guidelines really result in improved healthcare. Rather, their job is to ensure guideline compliance from both hospital employees and nonemployees who practice within the hospital.

Lastly, the administrators within a hospital have several incentives to preserve the guideline status quo. Administrators are often paid bonuses for ensuring guideline compliance. In addition to this direct financial incentive, administrators can often lobby for increases in pay since with the increase number of personnel employed to ensure guideline compliance, the administrators now supervise more employees, an important factor in determining their salary. Furthermore, success in improving compliance, allows administrators to advertise both themselves and their hospital as “outstanding”.

In addition, guidelines allow administrative personnel to direct patient care and indirectly control clinical personnel. Many clinical personnel feel uneasy when confronted with "evidence-based" protocols and guidelines when they are clearly not “evidence-based”. Such discomfort is likely to be more intense when the goals are not simply to recommend a particular approach but to judge failure to comply as evidence of substandard or unsafe care. Reporting a physician or a nurse for substandard care to a licensing board or on a performance evaluation may have devastating consequences.

There appears to be a discrepancy between an “outstanding” hospital as determined by the Joint Commission guidelines and other organizations. Many hospitals which were recognized as top hospitals by US News & World Report, HealthGrades Top 50 Hospitals, or Thomson Reuters Top Cardiovascular Hospitals were not included in the Joint Commission list. Absent are the Mayo Clinic, the Cleveland Clinic, Johns Hopkins University, Stanford University Medical Center, and Massachusetts General.  Academic medical centers, for the most part, were noticeably absent. There were no hospitals listed in New York City, none in Baltimore and only one in Chicago. Small community hospitals were overrepresented and large academic medical centers were underrepresented in the report. However, consistent with previous reports, we found that larger predominately urban, academic hospitals had better all cause mortality, surgical mortality and surgical morbidity compared to small, rural hospitals (1).

Despite the above, I support both guidelines and performance measures, but only if they clearly result in improved patient centered outcomes. Formulating guidelines where the only measure of success is compliance with the guideline should be discouraged. We find it particularly disturbing that we can easily find a hospital’s compliance with a Joint Commission guideline but have difficulty finding the hospital’s standardized mortality rates, morbidity rates, length of stay and readmission rates, measures which are meaningful to most patients. The Joint Commission needs to develop better measures to determine hospital performance. Until that time occurs, the “quality” measures need to be viewed as what they are-meaningless measures which do not serve patients but serve those who benefit from their implementation and compliance.

Richard A. Robbins, M.D.

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Robbins RA, Gerkin R, Singarajah CU. Relationship between the veterans healthcare administration hospital performance measures and outcomes. Southwest J Pulm Crit Care 2011;3:92-133.
2. Available at: http://www.va.gov/health/docs/HospitalReportCard2010.pdf (accessed 9-28-11).
3. Williams SC, Schmaltz SP, Morton DJ, Koss RG, Loeb JM. Quality of care in U.S. hospitals as reflected by standardized measures, 2002-2004. N Engl J Med. 2005;353:255-64.
4. Werner RM, Bradlow ET. Relationship between Medicare's hospital compare performance measures and mortality rates. JAMA 2006;296:2694-702.
5. Peterson ED, Roe MT, Mulgund J, DeLong ER, Lytle BL, Brindis RG, Smith SC Jr, Pollack CV Jr, Newby LK, Harrington RA, Gibler WB, Ohman EM. Association between hospital process performance and outcomes among patients with acute coronary syndromes. JAMA 2006;295:1912-20.
6. Fonarow GC, Yancy CW, Heywood JT; ADHERE Scientific Advisory Committee, Study Group, and Investigators. Adherence to heart failure quality-of-care indicators in US hospitals: analysis of the ADHERE Registry. Arch Int Med 2005;165:1469-77.
7. Wachter RM, Flanders SA, Fee C, Pronovost PJ. Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure. Ann Intern Med 2008;149:29-32.
8. Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM.  Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA. 2010;303:2479-85.
9. Robbins RA, Klotz SA. Quality of care in U.S. hospitals. N Engl J Med. 2005;353:1860-1.
10. Padrnos L, Bui T, Pattee JJ, Whitmore EJ, Iqbal M, Lee S, Singarajah CU, Robbins RA. Analysis of overall level of evidence behind the Institute of Healthcare Improvement ventilator-associated pneumonia guidelines. Southwest J Pulm Crit Care 2011;3:40-8.

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.

Changes in Medicine: Job Security

Reference as: Robbins RA. Changes in medicine: job security. Southwest J Pulm Crit Care 2011;3:72-4.  (Click here for a PDF version).

A Medscape article entitled the “Six Biggest Gripes of Employed Doctors” listed job security as a major concern of hospital employed physicians (1). When I left fellowship, most junior physicians joined an established, group practice either as a salaried associate or with a guaranteed income. Few ventured into solo practice, especially in pulmonary and critical care where night calls are frequent and days off are rare. Usually after a few years, the associate became a partner. Partners were entitled to share in profits that they generated, and usually profits of the group. Now that many physicians are employees of hospitals or corporations rather than physician-controlled practices, marked changes in physicians’ business hiring and business practices are occurring.

Some observers don't think job security is a problem for physicians. I would agree. Doctors are in demand and nearly every physician can find a job. Matt Robbins, Senior Director of Marketing for Delta Physician Placement in Dallas, points out that hospitals will hire more physicians as healthcare reform expands coverage and increases the emphasis on care coordination (1). However, the physicians of the future may question the cost of medical school, residency, and fellowship to enter into a “master-servant” relationship with an employer.

For example, a radiologist with a long term private practice relationship with a hospital for many years was told that the hospital was severing this relationship in order to form an all employee model. However, he and his private practice colleagues were given the opportunity of joining the new hospital radiology group. Now his income is dependent on his productivity. It is difficult for him to find time to teach, discuss cases with consultants, or participate in conferences without a financial penalty.

Several of the Phoenix pulmonary and critical care fellows were previously employed as hospitalists. One was jobless after the group that had provided hospital services for services for several years did not have their contract renewed. The hospital hired their own hospitalists, mostly young physicians just out of training. However, within a few months most had left because of dissatisfaction, especially with the workload.

Although lack of physician productivity, hospital financial losses or hospital mergers have been cited as reasons for terminating or modifying physician contracts, it would appear that maximizing profits is more likely. In the “master-servant” relationship inherent with a hospital-employed physician, the downside may be increasing workload, decreasing income and declining autonomy. Although some would argue that this increasing competition is good for the patient consumer, the rising healthcare costs with declining physician income argue against this.

However, if a physician is unhappy, he or she can always leave. After all the relationship is “master-servant” not “master-slave” and most contracts can be cancelled with a few months notice. However, more and more contracts have noncompete clauses, requiring a physician not to practice within a certain distance after leaving (1). With many hospitals or hospital corporations expanding, many physicians may have to move from their previous practice area, even from a large metropolitan area. There is also the possibility that if the separation is acrimonious, the quality assurance process can be used make a physician’s relocation even more difficult. While the hospital administrator has the option of complaining about a physician, the reverse is often not true. Hospital employed physicians are frequently required to sign contracts stating that they cannot discuss their employment.

The negative side of hospital employment should cause physicians to pause and carefully examine a contract. The negatives may outweigh the positives. Furthermore, with hospital mergers and administrators frequently changing, even the best situation could quickly deteriorate.

What is needed is increased oversight of the physician-hospital relationship. First and foremost, an administrator directing or pressuring physician employees to order certain tests, prescribe certain medications, etc. is an unlicensed practice of medicine by the administrator. It increases the cost of healthcare by the ordering of unnecessary testing, procedures, or therapy where profit margin is more a consideration than patient benefit. This should be reported to state licensing agencies. Second, it is questionable that hospitals should be allowed to hire physicians. California has a law prohibiting hospital or corporation ownership of physician’s practices (2) but the law is complicated and appears to be largely unenforced (3). As hospitals hire more physicians, laws to protect both patients and physicians from unscrupulous hospital administrators need to be both enacted and enforced. Third, physicians should be wary of noncompete and no discussion clauses in contracts. These are red flags that could signal potential dire professional and financial consequences to a physician who is in a difficult employment which they wish to leave.

Richard A. Robbins, M.D.

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Terry KJ. Six biggest gripes of employed doctors. Medscape Business of Medicine 2011. http://www.medscape.com/viewarticle/737543 (accessed 8-22-11).
2. http://www.mbc.ca.gov/licensee/corporate_practice.html (accessed 9-23-11).
3. Fichter AJ. Owning a piece of the doc: state law restraints on lay ownership of healthcare enterprises. Journal of Health Law 2006:39:1-76.

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.

Changes in Medicine: the Decline of Physician Autonomy

Reference as: Robbins RA. Changes in medicine: the decline of physician autonomy. Southwest J Pulm Crit Care 2011;3:49-51. (Click here for a PDF version)

Thirty years ago when I left fellowship, there were predominantly two career paths, private practice or academics. I had chosen academics by virtue of doing a fellowship at a heavily research-based program, the National Institutes of Health (NIH). However, even at the NIH many of my colleagues eventually ended up in private practice, which was more lucrative and much more common than the academic practice I chose. Now a third path has become more common, practice as a hospital employee. I became a hospital employee over 30 years ago when I became a part-time, and later, full-time physician at a Department of Veterans Affairs (VA) medical center affiliated with a university. Apparently I was ahead of my time. In an article entitled “Majority of New Physician Jobs Feature Hospital Employment” 56% of physician search assignments by the national physician search firm Merritt Hawkins in 2011 were for hospitals (1). This had increased from 51% in 2010 and 23% in 2006. In contrast, only 2% of the firm's 2011 search assignments featured openings for independent, solo practitioners, down from 17% in 2006. "The era of the independent physician who owns and runs his or her practice is fading," according to Travis Singleton, a senior vice-president at Merritt Hawkins.

The reason that hospitals want to employee physicians is obvious-money. By increasing market share and collecting professional fees, hospitals profit from physician employment. Physicians may be fearful of the cost of setting up a private practice with the increasing uncertainties of reimbursement, making a salaried hospital position attractive. This is especially true for a new physician not wishing to add to the debt incurred during training or seeking less than full-time employment for family or personal reasons (2).

Although quality or efficiency is often touted as a major reason for hospitals to employee physicians, recent research suggests that neither result. Kuo and Goodwin (3) reviewed over 50,000 Medicare admissions and found that hospital length of stay was 0.64 day less and costs $282 lower among patients receiving hospitalist care compared to primary care physician care. However, this reduction in inpatient costs under the care of hospitalists was more than offset by a $332 increase in charges after discharge.  Furthermore, patients cared for by hospitalists were less likely to be discharged to home; more likely to have emergency department visits; more likely to be readmitted to the hospital; less likely to have a follow up visit with their primary care physician; and more likely to be admitted to a nursing facility. As the authors point out this is nothing more than cost shifting, and hospitalists, who are typically hospital employees, may be more susceptible to behaviors that promote cost shifting. Consistent with this concept, O’Malley et al. (4) state that hospital employed physicians increase costs by higher hospital and physician commercial insurance payment rates and hospital pressure on employed physicians to order more expensive care.

Although the disadvantages of hospital employment are several, “Ultimately, the loss of control over their own professional lives is what irks employed doctors the most…” (5). As someone who worked as a hospital employee for the VA for over 30 years, I found an increasing “master-servant relationship” particularly annoying. Decisions were often based on financial or political considerations by nonphysicians or under-qualified clinicians. For example, some have recommended propofol as a standard in conscious sedation (6). It offers a number of advantages including ease of titration and short duration of action. Propofol has been used by our group for years in the ICU. Our group applied for “privileges” to use propofol for bronchoscopy which was endorsed by the pharmacy and therapeutics committee. Yet, the clinical executive board denied the application which our group found puzzling.  I was later told by a quality assurance nurse that the basis of this decision was that propofol is what killed Michael Jackson.  Hopefully medical decision making meets a higher standard than the singular example of what may have happened to a pop star.

Another example is the guidelines from groups like the Institute for Healthcare Improvement (IHI) that quickly becomes hospital mandates. Many of these guidelines are, at best, weakly evidence based (7). Furthermore, the guidelines are bundled, i.e., several guidelines are grouped together. Bundling makes it difficult, if not impossible, to determine which guidelines are effective. Most have probably had little impact on patient outcomes, but at least one proved to be catastrophic. Tight control of blood sugar in the intensive care unit was mandated and monitored by the VA based on IHI recommendations. However, as demonstrated in the NICE-SUGAR study, tight control actually resulted in a 14% increase in patient mortality (8). This increase in mortality would translate to 9503 excess deaths at all VA hospitals between 2002 and 2009 or about 1 death for every 84 patients treated with tight control of glucose. After publication of the NICE-SUGAR study the IHI dropped the issue from its web site and the VA switched to also monitoring hypoglycemia. One might think that a guideline which resulted in a 14% increase in ICU mortality would cause an outcry to punish those responsible, but instead resulted only in a deafening silence.

I am hopeful that we have trained our young physicians to practice for their patients’ benefit, rather than the financial or political well-being of the hospital. Yet, I fear that the financial pressures of beginning practice and protecting one’s reputation and livelihood may be too great a pressure to resist. Until physicians are not supervised by non- or under-trained administrators in a “master-servant” relationship, incidents such as the increase in ICU mortality secondary to tight control of glucose are bound to reoccur.

Richard A. Robbins MD

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Crane M. Majority of New Physician Jobs Feature Hospital Employment. Medscape 2011. http://www.medscape.com/viewarticle/744504?sssdmh=dm1.695421&src=nldne (accessed 8-22-11).
2. Robbins RA. Changes in medicine: medical school. Southwest J Pulm Crit Care 2011:3:5-7.
3. Kuo Y-F, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med 2011;155:152-9
4. O'Malley AS, Bond AM, Berenson RA. Rising hospital employment of physicians: better quality, higher costs? Center for Studying Health System Change (HSC) 2011. http://www.hschange.com/CONTENT/1230/#ib5 (accessed 8-23-11).
5. Terry KJ. Six biggest gripes of employed doctors. Medscape Business of Medicine 2011. http://www.medscape.com/viewarticle/737543 (accessed 8-22-11).
6. Eichhorn V, Henzler D, Murphy MF. Standardizing care and monitoring for anesthesia or procedural sedation delivered outside the operating room. Curr Opin Anaesthesiol 2010;23:494-9.
7. Padrnos L, Bui T, Pattee JJ, Whitmore EJ, Iqbal M, Lee S, Singarajah CU, Robbins RA. Analysis of overall level of evidence behind the Institute of Healthcare Improvement ventilator-associated pneumonia guidelines. Southwest J Pulm Crit Care 2011;3:40-8.
8. The NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009; 360:1283-97.

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.

Changes in Medicine: Fellowship

Reference as: Robbins RA. Changes in medicine: fellowship. Southwest J Pulm Crit Care 2011:3:34-36. (Click here for a PDF version)

Pulmonary fellowship in the late 70’s and early 80’s was largely unstructured.  I had the advantage of doing two fellowships. One was at the University of Nebraska Medical Center and was predominantly clinical. There was one other fellow and we spent our time going to clinic, reading pulmonary function tests, supervising exercise testing,  doing consults, and providing inpatient care both on the floors and the intensive care unit (ICU). We became involved with most of the patients in the ICU who were there for more than a day or two. The work was long and hard. We were mostly autonomous and only loosely supervised.

The attending physicians relied on us to call when we needed help or there was something we thought they should know. Call was at home but it was unusual to leave before 8 PM. The fellows alternated call every other weekend making it tolerable. There were plenty of procedures.  I did over 150 bronchoscopies my first year and performed sufficient numbers of intubations, thoracentesis, chest tubes, pulmonary artery cathers, etc. to be comfortable. There was little time or emphasis on research or other scholarly activity.

The other fellowship at the National Institutes of Health was the opposite. Research was clearly emphasized and most of our time was spent in the laboratory. Patient care was confined to patients on research protocols or consults to other services who had patients with incidental pulmonary problems. Procedures other than our research based protocols were rare.

At the time there were few critical care fellowships.  A fellow interested in the ICU usually entered a pulmonary fellowship or more rarely a cardiology fellowship. Anesthesia also practiced in the ICU at some institutions. Pediatric ICUs were left to the pediatricians. The American Board of Internal Medicine did require 36 months of fellowship but only 12 months needed to be clinical which was largely undefined.

A number of regulatory agencies entered fellowship regulation during the past 30 years. Most importantly has been the Accreditation Council on Graduated Medical Education (ACGME). As with residencies, the ACGME accredits the fellowship, and therefore, makes the rules. ACGME now recommends 24 months of clinical activity with a host of training requirements pertaining to patient care and medical knowledge (1). In addition, requirements now exist for competencies in practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.  Procedural training such as bronchoscopy (minimum now at 100) and the newer procedures such as sleep studies and ultrasound are also recommended or required. Fellowship directors are familiar with the ACGME’s program information form (PIF) which now extends to at least 75 pages describing the program. In addition, much of the PIF is devoted to answering questions such as “Describe at least one learning activity, other than lecture, by which residents develop a commitment to carrying out professional responsibilities and an adherence to ethical principles” or “Describe the learning activity(ies) through which residents achieve competence in the elements of systems-based practice: work effectively in various health care delivery settings and systems, coordinate patient care within the health care system; incorporate considerations of cost-containment and risk-benefit analysis in patient care; and, advocate for quality patient care and optimal patient care systems and work in interprofessional teams to enhance patient safety and care quality”. So the educational requirements to meet patient care and medical knowledge requirements as well as the newer requirements have been greatly extended leaving little time for scholarly activity or research. Many, if not most, fellows now leave their fellowship having never conducted a research study nor authoring a peer-reviewed manuscript.

Other organizations such as the Joint Commission of Healthcare Organizations, American College of Chest Physicians (2) and a variety of insurance carriers have waded in on credentialing requiring certain numbers of procedures for fellows to be certified as competent. Although these requirements are not unreasonable, they are arbitrary and the evidence basis on which they were formed is unclear.

The amount of paperwork regarding fellowships has undoubtedly increased for both the fellowship programs as well as the fellows themselves tracking procedures, etc. The number of personnel necessary to administer these regulatory activities has also undoubtedly increased. Supervision of fellows has also increased with attending physicians having more input into patient care. However, whether these lead to better trained physicians or better patient care is unknown. My suspicion is that it has not, at least there appears to be no evidence that anyone benefits. On the other hand, the amount of resources spent on supervision and documentation may actually lead to a decrease in the resources available for important educational and patient care activities actually result in harm to the fellows and possibly the patients. Regulatory agencies should investigate before mandating or even recommending educational requirements. More commonly the agency convenes a group of “experts” for advice. Often there is no reliable data, and therefore, the “expert’ panel makes recommendations based on their opinions. Not only the regulatory agencies but the panels of experts need to show restraint in making recommendations when there is no data. We often tell our fellows that it is alright to say “I don’t know”. Regulatory agencies and expert panels should also be willing to admit their limitations.

Richard A. Robbins, MD

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. http://www.acgme.org/ (accessed 8-8-11).
2. Ernst A, Silvestri GA, Johnstone D. Interventional pulmonary procedures: guidelines from the American college of chest physicians. Chest 2003;123;1693-1717.

Changes in Medicine: Residency

Reference as: Robbins RA. Changes in medicine: residency. Southwest J Pulm Crit Care 2011:3:8-10. (Click here for a PDF version)

The most important time in a physician’s educational development is residency, especially the first year. However, residency work and responsibility have come under the scrutiny of a host of agencies and bureaucracies, and therefore, is rapidly changing. Most important in the alphabet soup of regulatory agencies is the Accreditation Council for Graduate Medical Education (ACGME) which accredits residencies and ultimately makes the governing rules.

Resident work hours have received much attention and are clearly decreasing. However, the decline in work hours began in the 1970’s before the present political push to decrease work hours. The residency I entered in 1976 had every third night call during the first year resident’s 6-9 months on general medicine or wards. It had changed from every other night the year before. On wards, we normally were in the hospital for our 24 hours of call and followed this with a 10-12 hour day before going home and getting some well needed sleep. The third day was again a 10-12 hour day before repeating the cycle. This averages over 100 hours per week. There was one week of paid vacation and days off were rare. Both days off and vacations were expected to be done on electives.

First year residents were often poorly supervised despite a senior resident being on call with every 2 interns. Attending physicians were never in the hospital at night. I remember being told by a senior resident, that he was going to bed but I could call him if there was an emergency I could not handle-but he expected me to handle any emergency. I got the message not to call him.

The reduction in work hours was driven by residency directors trying to recruit sufficient residents to fill their slots. Residencies that required every other night call or had indigent level salaries were quickly becoming noncompetitive. By the time I left residency after 3 years, call had decreased to every fourth or fifth night and salaries had risen from about $10,000/year to $14,000/year for first year residents.

The reduction in work hours was brought to public attention and accelerated by the Libby Zion case of 1984 (1). The 18 year old Zion died from a complication of the monoamine oxidase inhibitor she had taken prior to hospitalization exacerbated by administration of meperidine and possibly by cocaine. When her father, Sidney Zion, a journalist/lawyer, learned that her doctors had been medical residents covering dozens of patients and receiving supervision only by phone, he became convinced his daughter's death was due to inadequate staffing at the New York teaching hospital where she died. Determined to ensure that others not fall victim to the same gaps that he blamed for his daughter's death, he crusaded to change resident work hours and supervision with frequent editorials and public appearances.

Over several years a sequence of events occurred to keep Zion’s death in the public eye: a grand jury was called to investigate Zion’s death; the New York State health commissioner appointed the Bell Committee to make recommendations regarding work hours; and a civil lawsuit against the doctors and hospitals was filed by Sidney Zion. All deemed the hospital negligent for leaving a first year resident alone in charge of 40 patients that night. The Bell Commission recommended that residents could work no more than 80 hours a week or more than 24 consecutive hours and senior physicians needed to be physically present in the hospital at all times and these recommendations were adopted by New York State.

The ACGME under political pressure to deal with resident work hours, appointed the Work Group on Resident Duty Hours and the Learning Environment in September 2001. The work group recommended new ACGME standards that were remarkably similar to those of the Bell Commission and these were adopted by the ACGME in 2003 (2).

The rationale behind the work hour reduction is that by working fewer hours and under greater supervision the care delivered by more rested and supervised residents will be better. A tragedy, in addition to Ms. Zion’s death, is that 27 years later we still do not know if this basic premise is true. Although the reduction in resident work hours and the in house presence of attending physicians has undoubtedly increased costs, the impact on length of stay and mortality remain largely unknown (3). The observational, retrospective research that has been done on the impact of resident hour reduction has been sufficiently flawed to make conclusions difficult (4-6). This is unfortunately part of a common trend in administrative medicine, i.e., to initiate changes based on political pressure and later attempt studies to justify the changes.

Concern has been voiced that reduction in work hours and autonomy due to increased supervision may compromise resident education (7). Although there would appear to be little evidence to date supporting this one way or another, I add my voice to those who raise this concern. Making independent decisions is vital to the maturation of residents to independent physicians. The present trend of reducing work hours and increasing supervision, may delay that learning experience to the first year or two of independent practice where correction and constructive criticism are unlikely to occur.

As work hours of residents decline, as medical knowledge expands, and as medical care becomes more complex our residencies will be hard pressed to train competent physicians. One approach is to lengthen the residencies to compensate for the reduced work hours (8). Adding another year or two of residency and/or fellowship is nothing more than extending the indentured servitude of residents to teaching hospitals. 3-6 years of post-graduate training is enough and extending the resident’s time may be more to provide adequate in house coverage than to improve the residents’ education.

I would recommend some carefully designed studies to investigate the impact of shorter work hours. The impact on mortality and length of stay should be examined along with the resident’s fund of knowledge. Perhaps armed with some sound data policy makers can make sound decisions regarding resident education, something we might call evidence-based medicine.

Richard A. Robbins, M.D.

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Lerner BH. A Case That Shook Medicine. The Washington Post, November 28, 2006. Available at http://www.washingtonpost.com/wp-dyn/content/article/2006/11/24/AR2006112400985.html

2. Friedmann P, Williams WT Jr, Altschuler SM, et al. Report of the ACGME Work Group on Resident Duty Hours. 2002. Available at: http://www.acgme.org/DutyHours/wkgroupreport611.pdf

3. 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;360:2202-15.

4. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004;351:1838-48.

5. Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shoshan O, Wang Y, Bellini L, Behringer T, Silber JH.. Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. JAMA. 2007;298:975-83.

6. Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shoshan O, Canamucio A, Bellini L, Behringer T, Silber JH. Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. JAMA. 2007;298:984-92.

7. McCoy CP, Halvorsen AJ, Loftus CG, McDonald FS, Oxentenko AS. Effect of 16-hour duty periods on patient care and resident education. Mayo Clin Proc. 2011;86:192-6.

8. Larson EB, Fihn SD, Kirk LM, Levinson W, Loge RV, Reynolds E, Sandy L, Schroeder S, Wenger N, Williams M; Task Force on the Domain of General Internal Medicine. Society of General Internal Medicine (SGIM). The future of general internal medicine. Report and recommendations from the Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine. J Gen Intern Med. 2004;19:69-77.

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.