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Handoffs create risks, costs Dr. Mirkes says his program had to adapt its call schedules to the shift limits. But the changes “have increased the number of handoffs, so we are losing that con- tinuity of care. And more people taking care of one patient over a period of time means more risk.” With fewer interns on call, the pro- gram shifted some of the workload to others and increased the use of float teams at night. Since the work typically goes to more expensive senior staff and midlevel providers, however, Dr. Mirkes said it has been a “really big financial adjustment.”
In fact, the 2008 IOM report predict- ed that additional program costs associ- ated with shifting workloads could range up to $1.7 billion per year nationally. A 2010 study conducted for ACGME just before the reforms also found the changes could cost programs hundreds of millions of dollars, but noted possible savings between 2.4 and 10.9 percent if the policies help reduce preventable ad- verse events. Dr. Mirkes also fears that over the long term, the changes could lengthen residency training, which also would add to costs when GME funding and residency slots already are scarce. “I’m looking at whether after three years, they are prepared to go out and do pri- vate practice in the real world. And in internal medicine, it will be four years if it keeps up the way it is.” Third-year neurosurgery resident Colin Son, MD, says younger residents training in surgery specialties like his, which depend more heavily on continu- ous exposure to cases, have been partic- ularly vocal about their discontent with the shift limits.
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“One of the best experiences you can have in terms of learning value is be- ing the person who takes the first call in the emergency department, formulat- ing a plan on your own, and being there overnight” to follow through on the case, said Dr. Son, chair of TMA’s Resident & Fellow Section and a resident represen- tative to the TMA Council on Medical Education.
The changes impact upper-level train- ees, as well.
54 TEXAS MEDICINE June 2013 According to the NEJM surveys, 65
percent of residents reported that seniors were taking on more work from junior residents, and quality of life for senior residents mostly worsened. Dr. Son thought that by his third year at UTHSC San Antonio his schedule and training would get more flexible as he graduated. Instead, he finds himself tak- ing call more often because there are not enough interns. “We [senior residents] certainly have more work.” And because they are busier, they are not always available to assist and teach the interns. Dr. Sorrell says that so far she has not noticed the shift limits translate to poor- er patient care. “I don’t think the rules have changed patient care at all.” She has taken advantage of off-duty hours to sleep or rest, which may have improved her quality of life as a first- year resident — time she may have oth- erwise spent with her husband, who is not always around because he, too, is in training. So more time off does not necessarily mean more time to study to make up for some of the clinical ex- posure shortfalls associated with duty hour regulations, and she still may have worked as much in the end. She doesn’t anticipate the changes will extend her training beyond three years, but says residents will work hard- er to make up any lost opportunities during their upper-level years. “That’s the nature of medicine and how it is learned.”
Duty hours in general are beneficial
in providing structure and rest for resi- dents and likely are here to stay, he says. “But as strict as the rules have become, we may need to reevaluate them.”
Finding the magic number Most of the studies to date are based primarily on perceptions, versus clinical and educational outcomes. Researchers and educators acknowledge the need for more study. ACGME’s Dr. Weiss says that will take time, but the recent findings still raise concerns worthy of consideration, along with emerging literature on resident ed- ucation, sleep, and well-being. But there is nothing inherently wrong
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