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PPhysician training has long been renowned for marathon teams, sleepless nights and holidays. But this began to change in 2003, when the medical profession imposed restrictions on hours of work during residency. However, experts ask, can we train residents in fewer hours while making good doctors?
A new study in the BMJ say yes. The researchers, led by Dr. Anupam Jena, professor of health care policy and medicine at Harvard Medical School, examined the performance of internal medicine physicians in their first year of unsupervised medical practice after their training completed.
They compared the results for patients from two groups of physicians: those trained before 2003, when the standard work week was 100 hours; and those trained later under the new rules, which limit to 80 weekly hours, with no individual shift exceeding 30 hours. For the three quality measures examined – mortality within 30 days of hospitalization, readmissions, and hospital services used (effectiveness measure) – they found no difference between the groups.
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In reviewing the data on the sickest patients in the hospital, "a group of patients for whom the experience and training of a doctor are really important," Jena said, the authors Still found no difference between these three results.
"It's rather reassuring," said Dr. Sanjay Desai, director of the Johns Hopkins Residency Program in Internal Medicine, who did not participate in the study.
Jena and her team based their analysis on a random sample of patient records from the Medicare database, including 450,000 hospitalizations in more than 4,000 hospitals in the United States, for each year from 2000 to 2012.
Although the data is old, Desai said it was a timely document. Other reforms have been made after 2003, but the maximum 80 hour and 30 hour limits discussed in this paper are similar to what is happening in practice today, he said. Since 2017, when the last reform has been implemented by the Accreditation Council for Higher Medical Education, the ceiling remains 80 hours of clinical and educational work per week on average over a period of four weeks, no quarter not exceeding 28 hours.
Dr. Thomas J. Nasca, CEO of the Accreditation Group, said in a statement that the study supported his rule of thumb, "which allows maximum flexibility while promoting patient safety," he said. improving the quality and well-being of physicians.
Jena said he chose to study only the first year of his new doctor career, because that is when the effects of residency training should be more obvious. "If the doctors who just finished their residency did not have enough training because they work fewer hours," he said, "then we should expect to find some differences very early 'before the' real world 'experience.
In 2006, Dr. Jay Bhattacharya, co-author, professor of medicine and economics at Stanford University, watched the mortality patients treated by residents before and after the changes implemented in 2003. He found that the weekly hours cap reduced the short-term mortality of high-risk patients.
"Previous literature said that tired doctors hurt and kill patients. In 2006, short-term results showed that a reduction in the number of hours of residence reduced mortality in hospitals. But nobody has evaluated the quality of doctors for a long time, "said Bhattacharya.
"This study is unique because it looked at the results after the training," said Desai.
The study also found that doctors with 10 years of experience provided better care than first-year doctors, as expected, but the difference in care was the same, as new doctors trained before or after the ceiling is put in place. During the 10 years studied, the research team also found a decrease in overall mortality, which explains national trends suggesting that hospitals provide better care overall, Jena said.
The authors noted that in a hospital setting, doctors work in large teams with specialists, nurses, social workers, and other experienced practitioners, which mitigates the impact of a only doctor on the results for the patients.
What we need to know next, said Desai, is what residents do with their 80 hours. How much time is spent with patients? On the computer? Do procedures?
"The real meaning at the hospital is where you spend those hours," Desai said. "In addition to [examining] Patient safety outcomes, we need to think very seriously and study more rigorously how doctors are trained "during residency.
One of the limitations of the study, mentioned by both Desai and the authors, is that it only concerned one specialty – doctors of internal medicine. Surgeons and other physicians who perform procedures may be affected differently by hourly restrictions as this would limit the number of procedures they perform under supervision.
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