This article has been updated to remove comments that were not original observations by an invited participant.
Next year's crop of internal medicine interns will be part of a one-year national randomized control trial (Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education, or iCOMPARE) to evaluate the impact of 16-hour shift caps on patient safety and trainee education.
We reached out to physicians by email to ask:
Should the 16-hour duty hour limit for interns be reconsidered?
The participants this week:
Vineet Arora, MD, hospitalist and quality improvement researcher at the University of Chicago and member of the iCOMPARE advisory board
Adam Bitterman, DO, PGY-5 in orthopedic surgery at North Shore/Long Island Jewish Health System, Plainview Hospital, Plainview, N.Y.
Alexander Djuricich, MD, program director of the internal medicine/pediatrics residency at Indiana University in Indianapolis
Anupam Jena, MD, PhD, internist at Massachusetts General Hospital in Boston, Mass., and health services researcher at Harvard
Aaron Stupple, MD, PGY-3 in internal medicine at Beth Israel Deaconness Medical Center, Boston, Mass.
Cons of the Cap
Adam Bitterman, DO: "As an orthopaedic surgery resident it is very difficult to comment on the workload of other specialties. Within orthopaedics, the pathology that is seen is constantly changing and the severity of these injuries is not necessarily related to the time of day. With that being said, it is an unfortunate reality that certain orthopaedic interventions will never been seen throughout one's 5-year training period due to a 'routine' workload, and then to limit it even more may be disastrous."
Data Are Needed
Vineet Arora, MD: "Yes. Given the importance of ensuring that our residencies graduate competent doctors capable of caring for patients independently, it is critical for medical educators and accreditors to rigorously evaluate the impact of major policy decisions such as the 16-hour rule on resident education and patient care."
Anupam Jena, MD, PhD: "Duty hour reform is so contentious almost exclusively because physicians hold their own training experiences dear and because there is a relative lack of rigorous scientific evidence to support the various models that have existed in the last decade. Were [randomized control trials] conducted that demonstrated that 16-hour shifts are superior to longer shifts in both patient safety and resident well-being, it would be difficult for opponents to argue against 16-hour shifts."
Aaron Stupple, MD: "The iCOMPARE trial is an attempt to measure what is difficult to measure, and it is crucial that we continually reconsider the best way to train and to care. Just as we have to tread carefully to avoid overwhelming patients with too many choices, we also need to be sure our efforts to curb housestaff abuse are actually working and do not invalidate the medical education mission. I think we should continually reevaluate ourselves."
Alexander Djuricich, MD: "I applaud the authors of the iCOMPARE and the [Flexibility In duty hour Requirements for Surgical Trainees, or FIRST] trials who attempt to address 'which is better for patients?' with regards to duty hours. By randomizing training programs to the current ... rules ('control group') and to 'overnight call' ('intervention group') and evaluating patient outcomes, the educator community can best determine the science behind duty-hour restrictions and how they impact patient care. Reconsideration of the duty-hour limit may result from interpreting the outcomes from iCOMPARE and FIRST, especially if they demonstrate improvement in the intervention group.
"Many in medicine were upset that the new rules were enacted with minimal scientific basis behind them. Like many educators, I am looking forward to the findings of this educational intervention. Whichever the outcome, I hope that educational leaders use the results to enact trainee schedules that will ultimately be best for patient care."
One Year Isn't Enough
Jena: "There is a critical piece that should not be left out. Opponents of reduced duty hours are rightly critical that with reduced duty hours we are not adequately preparing residents for independent practice as attending physicians. This could be true, but this is an empirical question that iCOMPARE will have the ability to answer.
"The trial, in my opinion, should not only consider contemporaneous outcomes of residents trained in different duty hour environments, but should follow these residents as they enter independent practice. The goal should be to understand how different training models impact these physicians longer term, in patient outcomes, process measures of quality, and costs of care. Our own research suggests no differences in mortality or length of stay of physicians trained in reduced duty hour environments, but better measures of quality than those are needed."
Trainee Quality of Life Matters
Bitterman: "With today's medical world being one that revolves around evidence-based decisions, I don't know for sure that maintaining a 16-hour duty limit will in fact prevent or limit patient morbidity. I think further study needs to be done to evaluate the physician's well-being and compared with a prescreen prior to embarking on the difficult journey of graduate medical education."
Stupple: "How we treat our trainees greatly influences how physician culture views caretaking. The profession's growth from a paternalistic guild to one that increasingly seeks to match evidence with patients' wishes is mirrored in its transition from the days of The House of God to [Accreditation Council for Graduate Medical Education] work hour restrictions."
You may also be interested in these recent Friday Feedbacks:
Will IMPROVE-IT Trial Affect Primary Care?
Patients Must Take Part in Their Own Health
Whistleblowers in the Hospital
Friday Feedback is a feature that presents a sampling of opinions solicited by MedPage Today in response to a healthcare issue, clinical controversy, or new finding reported that week. We always welcome new, thoughtful voices. If you'd like to participate in a Friday Feedback, or suggest a topic, drop us a line or two.