As a surgery intern, Brent James worked 90 to 120 hours a week and would take calls in the middle of the night that he wouldn't remember the next day.
Today, as one of two Utahns elected to the prestigious Institute of Medicine, he welcomes its new report calling for changes in medical residents' work hours to improve training and reduce the chances of fatigue-related medical errors.
Still, he isn't convinced changes will make a dramatic difference in the number of medical mistakes. At Intermountain Healthcare, where he is chief quality officer, its research shows that 96.5 percent of patient injuries stem from indirect problems -- such as an unexpected reaction to a drug a patient has never taken before -- rather than a specific human mistake.
"But it's still a good idea, it still has value," said James. "We know that if people are too tired they will make mistakes."
The report released today, Resident Duty Hours: Enhancing Sleep, Supervision and Safety, does not suggest changing the maximum number of hours doctors-in-training can work in a week. That standard -- 80 hours-- was set in 2003 by the Accreditation Council for Graduate Medical Education. (ACGME)
Instead, it advises that residents shouldn't work too long without sleep and should have more days off. Moonlighting during off-hours should also be restricted.
It also warned that violations of the 80-hour limit occur frequently and are underreported. The ACGME should more closely monitor teaching hospitals' compliance, it said.
Two ways to reach the goals set by the institute: residents could work a maximum shift of 16 hours, or they could work a 30-hour shift provided that they get an uninterrupted five-hour break for sleep after working 16 hours. Sleep breaks would count toward their 80-hour weekly limit.
The report also recommends greater supervision of residents by experienced physicians, limits on patient caseloads based on residents' levels of experience and specialty, and overlap in schedules during shift changes to reduce the chances for error during the handover of patients from one doctor to another.
"These requirements are not completely unreasonable," James said. "The real trade off is the cost."
The education system would have to adjust, perhaps requiring residents to train longer, he said. More work would also be passed on to mid-level practitioners and trained physicians -- a move that could cost teaching hospitals $1.7 billion a year, requiring additional federal funding, the report says.
"It couldn't come at a worse time," James said, "when right now the system is just reeling under the cost of health care."
James, also the executive director for the Institute of Health Care Delivery Research, noted patient injury rates have not significantly dropped since the ACGME set the 80-hour requirement five years ago.
It's for that reason, said Larry Reimer, associate dean of graduate medical education at the University of Utah, that no hard-and-fast changes will be made to residents' schedules until the ACGME requires it. "Nothing is really proven at this point," he said.
When possible, however, it may make sense for the U.'s residents -- who work 30-hour shifts -- to get some uninterrupted sleep and to allow for an additional day off each month, he said. Its 690 residents work at University Hospital and Clinics, as well as other hospitals like Intermountain Medical Center, Primary Children's Medical Center and St. Mark's Hospital.
Residents are beginning to express more interest in balancing work with their personal life and achieving a general sense of well being, Reimer said. But they still "feel a commitment to patients and don't necessarily feel like they want to bail out on patients when they're needed."
lrosetta@sltrib.com
