In response to a lack of concrete data on duty hour requirements for internal medicine residents, the Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education organization launched an ongoing study that requires first-year interns at Yale-New Haven Hospital and 62 other internal medicine programs to participate in 28-hour shifts.
The internal medicine residency program at YNHH is participating in the study, which began July 1 and will end June 30, 2016, in order to gain information on how to best train residents, according to Mark Siegel, program director of the Internal Medicine Traditional Residency Program. Siegel stated that this particular study offers the medical education community — and society at large — an opportunity to answer key questions about the best way to educate resident physicians while focusing on the key outcomes of patient safety and resident, particularly intern, well-being. While controversy continues in the medical community as to whether longer resident shifts or handoffs — when a physician transfers patient duty to the next doctor on call — are more error-prone, resident directors at YNHH all agreed the study’s question is an important one to investigate. The internal medicine program at YNHH hopes to use the data to optimize training methods in the future.
Siegel also pointed out that shorter work shifts with strict regulations on when a resident must leave the hospital could have a negative impact on an intern’s well-being, because interns are then under pressure to finished their work faster.
“There may be some concerns about intern safety when completing overnight shifts,” Siegel said. “There is significant observational data that [intern safety is] compromised by shorter work shifts. They might be stressed out by work compression — having to leave hospitals by certain deadlines. With all this as background, there is a lot of uncertainty in the educational community regarding the best way to train interns. This is an opportunity to answer those questions.”
YNHH Pediatric Residency Program Director Andrea Asnes agreed that studying work-hours is important for the medical community. As a program director, Asnes said the length of her residents’ shifts “plagues” her, adding that the well-being of her residents is “always on [her] mind.” She recalled that her own experience as a resident in New York staying at the hospital past her regulated 24-hour shifts to check on her patients in the morning was a “powerful experience.”
Asnes said that from an educational standpoint she prefers longer work shifts to an increased number of handoffs between doctors, but stated that it is hard to argue with the science of sleep and the fatigue data that has been collected. Adding that both methods have inherent flaws, Asnes said the YNHH pediatric residency program has worked to include ways of standardization to make handoffs safer including “talk back” of patient data — a method shown in studies to decrease errors in handoffs. During a “talk back,” the next doctor on call will physically repeat the information back to the departing doctor, thereby confirming its accuracy. Granted that her residents had the option to refuse participation on their own grounds, Asnes said she would have loved to have the pediatric residency program participate — like the internal medicine program — in a study similar to this one, and is “deeply interested” in the results.
Zi Wang, a postgraduate year one internal medicine resident, is an intern who ranked the Yale-New Haven internal medicine program high on his match list as an applicant. When applying to different residency programs, an applicant will rank their preferences while the residency program does the same for their applicants. Wang, who knew he would be required to participate in the study if matched with the Yale-New Haven program, said he did not believe participation in the study would largely impact his training outcome and was interested in the study as he applied to programs.
Wang added that although the ethics of the study do not bother him personally, he could see both sides of the argument on informed consent since the match system ultimately decided if he and other residents who were subjects in the study would have to participate. He added that in his experience, fatigue sets in during the twentieth hour of a shift.
“In the last eight hours, you are really unable to take in any new information or learn anything. You may miss things and you are really on autopilot. At the end of my shift, I feel sometimes I am [not as] good of a clinician,” Wang said.
The study, which has main sites at the University of Pennsylvania, John’s Hopkins and Brigham and Women’s Hospital ,was approved by the National Institutes of Health, according to Gary Desir, interim chair at Yale-New Haven’s Department of Medicine.