As of July 1, medical interns around the country will be required to work fewer hours per day but with more supervision, and will be forbidden to moonlight within their hospital or elsewhere. Those changes, mandated by the Accreditation Council for Graduate Medical Education (ACGME) in September last year, are drawing a mixture of praise and concern from the Yale medical community.
The most controversial change involves duty hours. Currently residents may work no more than 80 hours per week and no more than 24 hours continuously (plus up to six additional hours for transfer of patient care). The new rules will put interns—first-year residents—into a separate category. They can still work up to 80 hours but their shifts must end after 16 hours with no extra time for transfer of care. Interns at Yale are already barred from moonlighting.
Rosemarie L. Fisher, M.D., HS ’75, professor of medicine and pediatrics, and associate dean of graduate medical education, sat on the 16-person ACGME task force that devised the new rules. “I’m getting things thrown at me,” she said, “like ‘Why did you do this?’ ”
The answer, she said, is based on the intersection of two factors: the interns’ minimal level of training and growing evidence of problems caused by sleep deprivation. Sleep deprivation among interns has been linked to errors in patient care and medication administration, as well as to car accidents after long shifts. Extreme fatigue also hinders the ability to learn. “All of us on this task force believe we need graduated responsibility for patient care,” said Fisher, “and to do that we need to have the least trained, least competent people get more time off initially to learn and to get enough sleep so they’re not impaired.”
Others aren’t so sure. Peter Herbert, M.D. ’67, chief of staff and senior vice president for medical affairs at Yale-New Haven Hospital (YNHH), said, “My major concern is that this may diminish the quality of the interns’ education and put them a little farther behind at the end of a year. Their perception of the overall course of illness obviously changes when they see less of it.” Moreover, Herbert said, they are not considered the key decision makers at any time of day—that role is for attendings and senior residents. “We’ll do our best to ensure that their education is as complete as possible, but there’s no substitute for being in the hospital.”
Jason Ackerman, M.D., one of Yale’s current 170 interns, questions the notion that cutting interns’ hours will prevent mistakes. “If the reasoning is that you make poor decisions after so many hours of not sleeping,” he said, “it makes more sense to cap the hours of the senior resident, who ultimately makes the decisions and needs to be more rested and alert than the intern.”
But like Fisher, Ackerman believes that experience can make a difference when fighting fatigue. When facing a medical situation, interns must go through a mental checklist—a task more difficult when exhausted but second nature with experience. He also agrees that more rest could improve learning. “At the end of a 30-hour call shift, it really is hard to absorb anything, no matter what the lecture or teaching point is.”
Another concern is that as interns work fewer hours, there will be more patient handoffs. “We know handoffs between team members always increase error rates,” said Asghar Rastegar, M.D., professor of medicine.
That’s where another new rule comes in. As of July 1, a supervising physician must now be physically present or immediately available within the hospital to help ensure safe handoffs and patient care by interns. Fisher believes that this close supervision will also enhance the interns’ education. Herbert notes that Yale-New Haven already has intricate protocols and electronic systems for handoffs, established in response to rule changes mandated in 2003.
Although the interns’ reduced hours must be filled by other personnel, Herbert doesn’t foresee a big increase in spending—again because of Yale’s response to the 2003 rules, which included expanding Yale-New Haven’s Hospitalist Service by bringing in dozens of physicians, physician assistants, and nurse practitioners.
Other changes in response to the rules are in the planning stages, according to Herbert, Fisher, and Rastegar. “The interns are understandably anxious,” said Rastegar, “partly because the devil you know is better than the one you don’t. But I think things will settle down. And the bottom line is that we are not going to negotiate on the mission and our goals.”