New York Times Article on Changes in Resident Hours

On August 5, The New York Times Sunday Magazine ran an article on the changes in resident work hours.  In “The Phantom Menace of Sleep-Deprived Doctors,” writer Darshak Sanghavi claims that the new changes in resident work hours has not, as it was intended, had a positive impact on patient safety.  Residents may no longer be working 100 hour weeks, but patients, the author contends, are still experiencing significant harm.  In the article, the author focuses on the work of physician Christopher Landrigan whose studies of sleep-deprived doctors — like the death of Libby Zion in 1984  — helped to convince legislators and medical school accrediting bodies to limit the work hours of physicians-in-training.  Sanghavi cites some of Landrigan’s studies well as explanations of ACGME duty hours

The bulk of the article debunks the idea that there is a real correlation between sleep-deprived residents and patient harm.  As the author puts it, “But this is where the neat story of the correlation between doctor fatigue and hospital error hits a wall. Landrigan’s research was compelling, but his study was small and controlled. In normal, day-to-day practice in hospitals across the country, medical errors didn’t fall when work hours were reduced. A massive national study of 14 million veterans and Medicare patients, published in 2009, showed no major improvement in safety after the 2003 reforms. The researchers parsed the data to see whether even a subset of hospitals improved, but the disappointing results appeared in hospitals of all sizes and all levels of academic rigor. “The fact that the policy appeared to have no impact on safety is disappointing,” says David Bates, a professor at the Harvard School of Public Health and a national authority on medical errors.”  Landrigan, he says, was “dumbfounded” by this evidence and, painting the renowned researcher into a corner, he continues to assail the idea that changes in resident duty hours will positively impact patient care.

What is dumbfounding is the fact that anyone would think that changing one variable in health care would have a revolutionary impact on patient safety.  I completely agree with Landrigan’s conclusions and applaud the changes in resident duty hours.  But let’s face facts.  Fact number one, moving to 16- hour days instead of 20- hour days or even 36- hour stretches at a time is hardly a revolution.  We know that errors go up after eight hours on the job, so how can we expect them to be dramatically reduced if people are still staying up for 16- hours at a stretch.  What is more significant, however, is the fact that resident duty hours are only one of the slices in the Swiss cheese that lead to patient harm.  What do I mean by Swiss cheese.  I am referring here to James Reason’s Swiss cheese theory of error which explains that catastrophic errors occur not because of the actions of individual actors but because of system problems.  Each layer of the Swiss cheese has to line up perfectly in order for an error to occur — in this case for a patient to fall through.  Doctors, whether in training or not, are only one slice of the package of cheese.  Unfortunately, neither journalists like Sanghavi nor his editors seem to understand that fact.  Looking at health care through the prism of the heroic medical narrative, they see only the medical actors on the health care stage.

The reality is far more complex.  For example, today in hospitals, nurses are now working 12 hour plus shifts.  Sometimes back to back.  Residents used to be the ones who were sleep-deprived.  Now nurses, who used to be the safety net in teaching hospitals, may be too tired to pay attention to catch an error that has been made by an novice physician.  Nurses also shoulder higher and higher patient loads and in their haste to run from one patient room to ano0ther, may not have time to attend to the details –like the a medication error.  Increasing hospital through-put has also increased the load of both novice and expert doctors.  We know that interrupted labor is a hazard.  If residents are now caring for more and more patients, they will face more interruptions.   Ditto for attendings.  Which is why Landrigan’s work, which appears in a book I have just co-edited with Ross Koppel entitled First Do Less Harm: Confronting Inconvenient Problems in Patient Safety — is so important.

I read stories like this and want to weep. Our societal and journalistic failure to understand that health care really is delivered by teams leads to coverage like this.  It’s a shame because it denigrates important innovations like changes in resident duty hours.  We need more of those changes not less but we’ll never get them until we get the fact that just as it takes a village to raise a child it takes a village to care for the sick.

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