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  • NEJM Survey: Work Hours Working?

    It has been almost two years since the Accreditation Council on Graduate Medical Education (ACGME) duty hour standards were released. The recommendation - note: not regulation - limits first year resident physicians to 16-hour shifts, a decrease from 24 hours.

    AMSA continues to say that the recommendations, which permit intermediate-level and senior residents to work 24-hour shifts, are not strong enough and we continue to urge the Occupational Safety and Health Administration, which is tasked with enforcing safety and health legislation, to address resident work hours.

    In last week's New England Journal of Medicine, results of a national survey conducted between December 2011 and February 2012, found that residents reported no improvement in education, total number of hours worked, or the amount of rest they were getting. In fact, many participants described the changes as detrimental, with the majority feeling less prepared to take on more-senior roles. Only quality of life for first-year residents was identified as having improved. The frequency of handoffs and workload for senior residents were both noted to have increased, whereas patient safety was deemed to be unchanged. Overall, only 22.9% of residents reported approval of the 2011 regulations. Read more here.

    What do you think? Are the recommendations strong enough? What else can be done?

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  • One Year After ACGME Regulations Implemented, Further Adjustments Needed

    This week marks the one-year anniversary of the Accreditation Council on Graduate Medical Education (ACGME) duty hour standards that limit first year resident physicians to 16-hour shifts, a decrease from 24 hours.

    But the recommendations, which permit intermediate-level and senior residents to work 24-hour shifts, are not strong enough, says the American Medical Student Association (AMSA), the nation’s oldest and largest, independent association for physicians-in-training. AMSA continues to urge the Occupational Safety and Health Administration, which is tasked with enforcing safety and health legislation, to address resident work hours.

    “AMSA would like to see the 16-hour shift applied to all residents, not just first year interns,” says AMSA National President Dr. Elizabeth Wiley, JD, MPH. “Our hope is that policymakers will recognize that providing Americans with access to quality health care includes duty hour restrictions to keep America’s patients and resident doctors safe.”

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  • Work-Life Balance of Residents

    Aliye Runyan
    Chair, AMSA Medical Education Team
    The University of Miami Miller School of Medicine

    I was recently talking to friend, who is an intern. She told me she didn't remember the last time she'd had a bite to eat. She'd been up for 16 hours. We talked about an article written by a classmate, also an intern, about the stress of his days. A fellow resident commented on it, something to the effect of "don't be weak, you haven't seen anything yet.”

    To some extent, this is the normalization/desensitization process that all residents must go through, in order to make it through the tough years of training, to be able to handle a full schedule with emergencies popping up at a moment's notice. This is understandable, it's what we go to med school for; it's what we train for.

    What is not understandable is how this aspect of the culture of medicine permeates to the very health and sanity of the physicians it trains. There is no honor in losing a grip on your own mental and physical well-being in the process of caring for your patients (which, as a resident, is less of that and more dealing with bureaucracy, paperwork, and miscommunication). The medical community, to some degree, has recognized this issue by way of one of its symptoms: patient deaths and countless medical errors, and had tried to deal with it in part with work hour regulations. This is surely a positive step; however criticized it may be as the regulations go from theory to practice. However, the onus is still on the community at large to self-police, and to shift perspective. 

    It begins with little things - a resident asking an intern if they have had something to eat (and vice versa), for instance, or finding more efficient ways to prioritize time with patients (more fulfilling than paperwork), and better care for the patient, which leads to higher satisfaction for the doctor. Honestly, it all comes down to the simplest concept - looking out for one another, as colleagues, as doctor to patient, as a community. There comes a point where the doctor is too sick, too tired, too burned out, too anxious - to be an effective clinician and decision- maker. 

    The analogy of doctors and pilots is sometimes overused, but the image works well. Would I want a pilot, having not slept for more than 16 hours straight, and not eaten for 8 of those hours, to fly the plane I'm on? The answer, without a second thought, is no. There is a very high likelihood, though, that your surgeon might be in this state. This should be a sobering thought. Providing good medical care need not come with the physical and emotional toll that is the status quo.

    I'll end with this: I was at a conference recently where an Australian physician gave a talk on work-life balance. I enjoyed his talk and went up to him afterward to say how hearing about balance is so necessary in our community, especially for young physicians as they go through training. I mentioned the work hour restrictions and generally explained the way hospital medicine is in the U.S. He looked at me incredulously. He works three days a week, taking care of his entire community in a small town in Australia. Work-life balance and preventive medicine is valued. "Come train with us!" he encouraged me. I'm more than a little tempted. Obviously, there are more than just work-life balance differences that make this lifestyle possible. The model, though, exists. 

    We have come far from the age of my grandfather's day as a doctor, where being a member of the "housestaff" literally meant you lived in the hospital. We have so far yet to go. As a community, let's strive for our health as well as the health of our patients. We are only as good of a doctor to our patients as we are to ourselves.

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  • Changing great expectations

    Andrea Knittel
    AMSA Member
    6th Year MSTP
    University of Michigan

    Post #4 of the "Back to the Wards" series focusing on the transition from research years back to the medical school and clinical rotations. 

    When I started medical school, there was substantial debate swirling about changing residency work hours, particularly for interns who were putting in untold hours at the hospital clearly to the detriment of their personal wellbeing, and potentially to the detriment of patient care.  These arguments sparked discussions of the best way to train physicians to work independently, how to maintain continuity of care without endless work hours, and even how to measure progress on these issues.  Ultimately, resident work hours were limited to 80 hours per week and shifts limited to 30 hours.  AMSA helped to draft the legislation that implemented these first changes, and continues to advocate for better conditions for residents and students. 

    As I’m preparing to return to the wards, the controversy has flared again, though this time regulations have already passed.  The 80 hour work week remains in place, but first year residents (interns) may only work 16 consecutive hours.  (In addition, as detailed in news articles here and here, stricter rules for how residents should be supervised were added, and other regulations to improve patient care and resident safety were also included.)  On the whole, I’m happy to see medicine becoming a safer and more user-friendly profession, and hope that reduced physician burn-out will be a additional consequence of these regulations. 

    In spite of these hopes, I nonetheless struggle with what a friend recently termed “competitive suffering.”  We’ve all experienced it before.  It’s what happens when you moan that you didn’t get enough sleep because you were writing a paper or studying for a test, and a colleague counters that he/she hasn’t slept in a week because of all of the work that needed to be finished.  Similarly, it occurs when one med student complains about an overnight shift on an OB/GYN rotation, and someone immediately pipes up that their transplant surgery rotation has required an unendingly flexible schedule and many sleepless nights.  Lately, I’ve noticed that it also happens when I express trepidation at the nights of call and night float I’ll be expected to work as a medical student, and my friends remind me that when they were in medical school, they were frequently in the hospital overnight, and that call expectations for medical students were much greater.  This often follows with exclamations of how much they learned at night because no one else was there, or of how amazing the patient was that they admitted in the morning and followed for a full 24 hours.  How is a returning student to deal with this, as medical student expectations are shifted with those of residents?  Certainly stepping back and saying “Wow, you had a rough go of it.  They sure do things differently now!” rarely feels like the right option, but most of the time, I think it is.  I try to remind myself that I learn more when I’m awake, and that my retention is laughable when I haven’t been able to sleep.  If that’s not enough, I think about the friends I’ve been lucky enough not to lose to drowsy driving accidents, or patients they’ve been lucky enough not to lose because of a sleepless error, and remind myself that these regulations mean that I’ll need to rely a little less on luck.

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  • Do you think the ACGME work hour recommendations are strong enough?

    This week, the Accreditation Council on Graduate Medical Education (ACGME) released resident work hour recommendations. If you haven't seen them, you can check them out here. What do you think of the recommendations - right on the money? or not enough?

    If you want to read AMSA's response to the recommendations, click here. Basically, AMSA thinks that they are a good step toward establishing evidence-based work hour scheduling for resident physicians HOWEVER, they would be stronger if the 16-hour shift applied to all residents. AMSA also hopes that the ACGME continues to monitor, enforce and update work hour regulations so that U.S. medical schools can maintain the highest standards of learning and self-care.

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