By: Catherine Foley,
on 6/5/2015
For many generations, doctors seemingly had little choice. Work came first. Doctors were expected to live and breathe medicine, spend long hours at the office or hospital, and, when necessary, neglect their families for the sake of their patients.
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By: Julia Callaway,
on 4/3/2015
It is axiomatic in medical education that an individual is not a mature physician until having learned to assume full responsibility for the care of patients. Thus, the defining educational principle of residency training is that house officers should assume the responsibility for the management of patients.
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By: Julia Callaway,
on 3/6/2015
A middle-aged man was recently admitted to a Midwest hospital for “refractory congestive heart failure.” He had been followed in the hospital’s out-patient clinic for two years with that diagnosis. Yet, he continued to retain fluid and gain weight, despite optimal treatment for congestive heart failure.
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By: Julia Callaway,
on 11/7/2014
Interns and residents have always worked long hours in hospitals, and there has always been much to admire about this. Beyond the educational benefits that accrue from observing the natural history of disease and therapy, long hours help instill a sense of commitment to the patient. House officers learn that becoming a doctor means learning to meet the needs of others. This message has never been lost on them.
However, it has also long been recognized that house officers are routinely overworked. This point was emphasized in the first systematic study of graduate medical education, published in 1940. In the 1950s and 1960s, the hazards of sleep deprivation became known, including mood changes, depression, impaired cognition, diminished psychomotor functioning, difficulty with interpersonal relationships, and an increased risk of driving accidents. In the 1970s, the phenomenon of burnout was recognized. In the mid-1980s, after prospective payment of hospitals was introduced, the workload of house officers became greater still, as there were now many more patients to see, the patients were sicker, the level of care was more complex, and there was less time with which to care for patients. House officers understood they were in a dilemma where their high standards of professionalism were used by others to justify sometimes inhumane levels of work.
Despite their long hours, the public generally believed that house officers provided outstanding medical and surgical care. Through the 1980s, the traditional view that medical education enhanced patient care remained intact. So did the long-standing belief that teaching hospitals provided the best patient care — in large part because they were teaching hospitals.
In 1984, the traditional belief that medical education leads to better patient care received a sharp rebuke after 18-year old Libby Zion died at the New York Hospital. Ms. Zion, a college freshman, had presented to the hospital with several days of a fever and an earache. The next morning she was dead. The case quickly became the center of intense media interest and a cause célèbre for limiting house officer work hours.
The public’s fear about the safety of hospitals increased in the 1990s. In 1995, a seeming epidemic of errors, including wrong-site surgery and medication and medication mistakes, erupted at US hospitals. These high-profile tragedies received an enormous amount of media attention. The most highly publicized incident involved the death of 39 year-old Betsy Lehman, a health columnist at the Boston Globe, from a massive chemotherapy overdose while being treated for breast cancer at the renowned Dana-Farber Cancer Institute. Public concern for patient safety reached a crescendo in 1999, following the release of the Institute of Medicine’s highly publicized report To Err Is Human. The report concluded that 48,000 to 98,000 Americans died in US hospitals every year because of preventable medical errors.
The result was that in the early 2000s, a contentious debate concerning resident work hours erupted. Many within the medical profession felt that work-hour regulations need not be imposed. They correctly pointed out that little evidence existed that patients had actually suffered at the hands of overly tired residents, and they also claimed that resident education would suffer if held hostage to a time clock. Critics, particularly from outside the profession, pointed to valid physiological evidence that fatigue causes deterioration of high-level functioning; they also argued that high-quality education cannot occur when residents are too tired to absorb the lessons being taught. As the debate proceeded, the public’s voice could not be ignored, for the voices of consumer groups and unions were strong, and Congress threatened legislative action if the profession did not respond on its own
Ultimately, the medical profession acquiesced. In 2002, the Accreditation Council for Graduate Medical Education (ACGME), which oversees and regulates residency programs, established new work-hour standards for residency programs in all specialties. Effective 1 July 2003, residents were not to be scheduled for more than 80 hours of duty per week, averaged over a four-week period. Over-night call was limited to no more frequently than every third night, and residents were required to have one day off per week. House officers were permitted to remain in the hospital for no more than six hours after a night on-call to complete patient care, and a required 10-hour rest period between duty periods was established.
Ironically, as the ACGME passed its new rules, there was little evidence that resident fatigue posed a danger to patients. The Libby Zion case, which fueled the public’s concern with resident work hours, was widely misunderstood. The problems in Ms. Zion’s care resulted from inadequate supervision, not house officer fatigue. At the time the ACGME established its new rules, the pioneering safety expert David Gaba wrote, “Despite many anecdotes about errors that were attributed to fatigue, no study has proved that fatigue on the part of health care personnel causes errs that harm patients.”
On the other hand, the controversy over work hours illustrated a fundamental feature of America’s evolving health care system: Societal forces were more powerful than professional wishes. The bureaucracy in medical education responded slow to the public’s concerns that the long work hours of residents would endanger patient safety. Accordingly, the initiative for reform shifted to forces outside of medicine — consumers, the federal government, labor, and unions. It became clear that a profession that ignored the public’s demand for transparency and accountability did so at its own risk.
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By: Alice,
on 7/4/2014
“Don’t get sick in July.”
So the old adage goes. For generations medical educators have uttered this exhortation, based on a perceived increase in the incidence of medical and surgical errors and complications occurring at this time of year, owing to the influx of new medical graduates (interns) into residency programs at teaching hospitals. This phenomenon is known as the “July effect.”
The existence of a July effect is highly plausible. In late June and early July of each year, all interns and residents (physicians in training beyond the internship) are at their most inexperienced. Interns—newly minted MDs fresh out of medical school—have nascent clinical skills. Most interns also have to learn how a new hospital system operates since most of them enter residency programs at hospitals other than the ones they trained at as medical students. At the same time the previous year’s interns and residents take a step up on the training ladder, assuming new duties and responsibilities. Every trainee is in a position of new and increased responsibilities. The widespread concern that these circumstances lead to mistakes is understandable.
Yet, despite considerable consternation, evidence that there is a July effect is surprisingly hard to come by. Numerous studies of medical and surgical trainees have demonstrated no increase in errors or complications in July compared with other times of the year. Many commentators have declared the July effect a myth, or at least highly exaggerated. A few studies have shown the existence of a July effect, but only a slight one—for instance, on the sickest group of heart patients, where even a slight, seemingly inconsequential mistake can have grave consequences. Even here, however, the magnitude of the effect does not appear large, and the studies are highly flawed. Certainly, there is no reason for individuals to avoid seeking medical care in July should they become ill.
That the July effect is so difficult to demonstrate is a tribute to our country’s system of graduate medical education. Every house officer (the generic term for intern and resident) is supervised in his or her work by someone more experienced, even if only a year or two farther along. Faculty members commonly provide more intense supervision in July than at other times of the year. Recent changes in residency training, such as shortening the work hours of house officers and providing them more help with chores, may also help make residency training safer for patients—in July, and throughout the year.
Uncertainty is intrinsic to medical practice. Medical and surgical care, no matter how skillfully executed, inevitably involves risks. It would not be surprising if a small July effect at teaching hospitals does occur, particularly in certain subgroups of critically ill or vulnerable patients, given that house officers are the least experienced. However, the fact that this effect, if present, is small and difficult to measure provides testimony to the strength of graduate medical education in the United States. Indeed, the quality of care at teaching hospitals has consistently been shown to be better than at hospitals without interns and residents. Patients may be assured that their interests will be served at teaching hospitals—in July, and throughout the year.
Kenneth M. Ludmerer is Professor of Medicine and the Mabel Dorn Reeder Distinguished Professor of the History of Medicine at the Washington University School of Medicine. He is the author of Let Me Heal: The Opportunity to Preserve Excellence in American Medicine, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care, and Learning to Heal: The Development of American Medical Education.
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Image credit: Multiracial medical students wearing lab coats studying in classroom. Photo by goldenKB, iStockphoto.
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