Wednesday, December 15, 2010

Work hour limits shouldn't be just for residents

Old farts need rest too, says Bob Wachter in a guest post at Kevin MD, citing a recent study of radiologists (both residents and attendings) showing deteriorating accuracy with increased fatigue.

Resident fatigue was the initial focus of the patient safety movement and even predated the IOM report by over a decade, as a result of the Libby Zion case. Have initiatives to address physician fatigue improved patient outcomes? Although we can't answer that question with data I'm sure the anecdotal evidence would be impressive, as any of us who trained in the pre-Zion era could attest.

I trained in the days of every third and every other night call when night float was not part of the lexicon. On your call day you went to work early and worked 36 hours straight. Maybe longer. You got home late on your post call day so your spouse could watch you sleep. You occasionally fell asleep while interviewing your patient---typically your sixth admission of the night, at 3 AM. The next day a malignant attending might chide you on the sloppy appearance of your hand written H and P. You didn't dare point out that you were just too tired. Too tired? they might ask incredulously. These anecdotes are comical. But what about mistakes with consequences for patients? How many of us really want to know?

Well, for residents, at least, things have changed. We've gone to the opposite extreme, perhaps even too far. The latest proposal is to require naps. It seemed silly to me in the first grade. I would welcome it now.

If efforts to reduce resident fatigue haven't meaningfully impacted patient safety maybe it's because of the unintended consequences or because no attempt has been made to address the equally important issue of fatigue on the part of practicing physicians. But as Bob points out this would be next to impossible to implement for those who practice in the eat-what-you-kill world of fee for service reimbursement.

So (and my conflict of interest here should be obvious) maybe hospitalists should be the next group to target. After all, many of them are treated as advanced residents anyway, and most are not paid by RVUs. For that to gain traction organized hospital medicine would need to set a standard. This might be a worthwhile project for the Society of Hospital Medicine.

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