Forbes.com, June 29, 2010, by Peter A. Lipson  –  Over a quarter century ago, a young woman was admitted to a New York hospital with fever and agitation. She never walked out. Libby Zion died while under the care of he primary care doctor and two medical residents. The exact cause of death was never identified, but the case led to a forced examination of medical residents’ work hours. This was driven largely by Zion’s father who felt that his daughter had been killed by inexperienced, poorly supervised, and overworked resident physicians.

“You don’t need kindergarten,” he wrote in a New York Times op-ed piece, “to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call — forget about life-and-death.”

It was largely thanks to Zion’s tireless work that in 1989 a bill was passed in New York State limiting resident work hours and requiring senior physicians to be physically present in the hospital. But though you might not need kindergarten to recognize this problem, you do need data. That came later.

Medical residents have traditionally worked long hours, especially in their first (“intern”) year. In fact, they used to “reside” in the hospital, and were universally young, male, and single. Now, graduating medical students are about 48% female, compared to just over 26% in 1982 (although age hasn’t changed much, which sort of surprised me).   The Libby Zion law limited resident work hours to 80 hours per week and 24 hour shifts.  During my internship in Chicago, we would typically work about 32 hours in a row on call and post-call, and call took place every fourth night,  which has long been typical for internal medicine residencies.

In 2003, the Accreditation Council on Graduate Medical Education (ACGME) instituted the first national work hour limitations for residents. These limitations looked very similar to those imposed by NY state. These work hour limitations required significant changes to how hospitals and residencies were run.  Hospitals can only support a certain number of residents, and they count on these residents and the care they provide.  Hospitals have had to reduce the number of patients cared for by residents, and has led to an increase in so-called mid-level providers (physician assistants and nurse practitioners).  And residencies had to find ways to accomplish the same or similar amount of work with the same personnel but with significant time constraints.

Many of these changes involved a more toward “shift work” and night float systems, where residents worked shifts of limited hours throughout a 24 hour day, handing off patients to the next shift.  This creates its own problems for both patients and residents.  There are concerns that shift work may lead to a disruption in continuity of care, since patients are being “handed off” potentially several times a day.  Also, residents are not supposed to be performing functions that are primarily “service” rather than educational.  During the day, residents can break away from clinical duties for educational conferences, but a 11pm-7am shift is all service.

These, and the urgent questions about the safety of both patients and residents were addressed in a comprehensive report released in 2009 by the Institute of Medicine, part of the National Academies.   While it makes sense that long sleep-free work hours might be dangerous to both patients and residents, knowing the data allows us to make proper, evidence-based decisions about these potential problems.

Resident Safety

As medical educators, we have a duty to our residents to ensure not only their education, but their well-being, at least as it relates to work. It is conceivable that long, sleepless work hours may have adverse health effects.  The 2009 IOM report summarizes some of the evidence for fatigue-related injury.  Many of this evidence is readily available through PubMed.  Needle stick injuries, for example, are a relatively common problem and there is evidence that these are related to fatigue.  There is also quite a bit of evidence that medical residents have an elevated risk for falling asleep at traffic lights and being involved in motor vehicle accidents.  And these data are not new.

Patient Safety

Data on patient safety isn’t new either.  A name that pops up again and again in this research is Charles A. Czeisler. He published a study in the New England Journal of Medicine in 2004 showing fairly convincingly that first-year residents in the ICU are at risk of committing significantly more medical errors when working extended shift vs. less onerous ones.  That’s just one good study of many.

Individual errors are inevitable, but as a phenomenon, errors can be reduced significantly, often through simple systems fixes.  One of these fixes is the implementation of reasonable resident work hours.

Denialism?

Responses in the literature and in doctors’ lounges have been tangential and almost intentionally obtuse.  A colleague of mine at another institution has opined that the medical profession is in a state of “institutional denialism” about the effect of long hours on safety and performance.  I don’t think that is unfair.  The evidence on this has existed for years, yet we’ve made only cosmetic adjustments to our training programs.  Even the latest ACGME rules (which take effect in July 2011) fail to address the most significant implications of the problem.  The work hour limitations they mandate will very likely help, but there is a larger systemic problem.  Medical training is lengthy and expensive.  If we’re going to cut back on hours, we need to re-evaluate whether the new hours are sufficient to meet educational needs.  If not, we are going to have to find a way to fund longer training programs and to fund the debt-ridden trainees who will spend extra years not paying their educational debt.    Quick fixes, even smart ones, aren’t going to do the trick.

The Libby Zion case that eventually led to the new work rules was over a quarter century ago.  How long will it take us to create real, comprehensive solutions?

References

Fisman, D., Harris, A., Rubin, M., Sorock, G., & Mittleman, M. (2007). Fatigue Increases the Risk of Injury From Sharp Devices in  Medical Trainees: Results From a Case‐Crossover Study•Infection Control and Hospital Epidemiology, 28 (1), 10-17 DOI: 10.1086/510569

Trinkoff, A., Le, R., Geiger‐Brown, J., & Lipscomb, J. (2007). Work Schedule, Needle Use, and Needlestick Injuries Among Registered  Nurses •Infection Control and Hospital Epidemiology, 28 (2), 156-164 DOI: 10.1086/510785

Steele, M., Ma, O., Watson, W., Thomas, H., & Muelleman, R. (1999). The Occupational Risk of Motor Vehicle Collisions for Emergency Medicine Residents Academic Emergency Medicine, 6 (10), 1050-1053 DOI: 10.1111/j.1553-2712.1999.tb01191.x

Barger LK, Cade BE, Ayas NT, Cronin JW, Rosner B, Speizer FE, Czeisler CA, & Harvard Work Hours, Health, and Safety Group (2005). Extended work shifts and the risk of motor vehicle crashes among interns. The New England journal of medicine, 352 (2), 125-34 PMID: 15647575

Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, & Czeisler CA (2004). Effect of reducing interns’ work hours on serious medical errors in intensive care units. The New England journal of medicine, 351 (18), 1838-48 PMID: 15509817

Gaba DM, & Howard SK (2002). Patient safety: fatigue among clinicians and the safety of patients. The New England journal of medicine, 347 (16), 1249-55 PMID: 12393823

Nuckols TK, Bhattacharya J, Wolman DM, Ulmer C, & Escarce JJ (2009). Cost implications of reduced work hours and workloads for resident physicians. The New England journal of medicine, 360 (21), 2202-15 PMID: 19458365

About the author…………

Peter Lipson MD

Peter A. Lipson, MD is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his Internal Medicine residency at Northwestern Memorial Hospital. He currently maintains a private practice, and serves as a teaching physician at a large community hospital. He also maintains an appointment as a Clinical Assistant Professor of Medicine in the Midwestern U.S. A primary goal of his writing is to illuminate the differences between science-based medicine and everything else. His perspective as a primary care physician and his daily interaction with real patients gives him what he hopes is special insight into the current “De-lightenment” in medicine. As new media evolve, pseudo-scientific, deceptive, and immoral health practices become more and more available to patients, making his job all that much more difficult- and all that much more interesting. Disclaimer:The views in all of of Dr. Lipson’s writing are his alone. They do not represent in any way his practice, hospital, employers, or anyone else.

The New York Times, June 29, 2010, by Tara Parker-Pope  –  Does your marriage need therapy? If you’re like most people, the correct answer may well be yes, but your answer is probably no.

In most marriages, one or both partners resist the idea of counseling. Some can’t afford it, or find it inconvenient. And many view therapy as a last resort — something only desperate couples need. Only 19 percent of currently married couples have taken part in marriage counseling; a recent study of divorcing couples found that nearly two-thirds never sought counseling before deciding to end the relationship.

“It seems like we’re even more resistant to thinking about getting help for our relationship than we are for depression or anxiety,” said Brian D. Doss, an assistant psychology professor at the University of Miami. “There’s a strong disincentive to think about your relationship as being in trouble — that’s almost admitting failure by admitting that something isn’t right.”

Marriage counseling does not always work, of course — perhaps because it is so often delayed past the point of no return. One recent study of two types of therapy found that only about half the couples reported long-lasting improvements in their marriages.

So researchers have begun looking for ways (some of them online) to reach couples before a marriage goes off the rails.

One federally financed study is tracking 217 couples taking part in an annual “marriage checkup” that essentially offers preventive care, like an annual physical or a dental exam.

“You don’t wait to see the dentist until something hurts — you go for checkups on a regular basis,” said James V. Córdova, an associate professor of psychology at Clark University in Worcester, Mass., who wrote “The Marriage Checkup” (Jason Aronson, 2009). “That’s the model we’re testing. If people were to bring their marriages in for a checkup on an annual basis, would that provide the same sort of benefit that a physical health checkup would provide?”

Although Dr. Córdova and colleagues are still tallying the data, preliminary findings show that couples who take part in the program do experience improvements in marital quality. By working with couples before they are unhappy, the checkup identifies potentially “corrosive” behaviors and helps couples make small changes in communication style before their problems spiral out of control. (Typical problems include lack of time for sex and blaming a partner for the stresses of child rearing.)

“Couples won’t go to marital therapy with just the one thing that they are struggling with,” Dr. Córdova said. “So they end up struggling in places where the fix might be simple, it’s just that they themselves are blind to it.”

Not surprisingly, some therapists are creating online self-help programs to reach couples before serious problems set in. Dr. Doss and Andrew Christensen, a psychology professor at the University of California, Los Angeles, are recruiting couples at www.OurRelationship.com to study such a program.

The online study, financed by a five-year $1.2 million grant from the National Institute of Child Health and Human Development, will deliver online therapy to 500 couples. It is based on “acceptance therapy,” which focuses on better understanding of a partner’s flaws — a technique described in “Reconcilable Differences” (Guilford Press, 2002), by Dr. Christensen and Neil S. Jacobson.

The method, formally called integrative behavioral therapy, was the subject of one of the largest and longest clinical trials of couples therapy. Over a year, 134 highly distressed married couples in Los Angeles and Seattle received 26 therapy sessions, with follow-up sessions every six months for the next five years.

Half the couples received traditional therapy that focused on better communication and problem solving, while the others took part in a similar program that included acceptance therapy. Five years after treatment, about half the marriages in both groups were significantly improved, according to the study, which appeared in the April issue of The Journal of Consulting and Clinical Psychology. Dr. Christensen says about a third of the subjects could be described as “normal, happy couples,” a significant improvement considering how distressed they were at the start. (The couples who received acceptance therapy had better results after two years, but both types of therapy were about equal by the end of the study.)

The hope is that an online version of the program could reach couples sooner, and also offer booster sessions to improve results. Even so, Dr. Christensen notes that the disadvantage of online therapy is that it won’t give couples a third party to referee their discussion.

“Nobody thinks it’s going to replace individual therapy or couples therapy,” he said. “There’s generally a sense that the intervention might be less powerful, but if it’s less powerful but is easily administered to many more people, then it’s still a very helpful treatment.”

Researchers at Brigham Young University offer an extensive online marital assessment, called Relate, for couples and individuals. The detailed questionnaire, at www.relate-institute.org, takes about 35 minutes to complete and generates a lengthy report with color-coded graphs depicting a couple’s communication and conflict style, how much effort each partner puts into the relationship, and other things. The fee is $20 to $40.

Australian researchers are using the same assessment, along with a DVD and telephone education program called Couple Care, found at www.couplecare.info, to reach families in remote areas who don’t have access to traditional therapy. The Utah and Australia researchers have begun a randomized, controlled trial of about 300 couples to determine the effectiveness of the approach.

Preliminary data show that couples reported improvement, but Kim Halford, a professor of clinical psychology at the University of Queensland, St. Lucia, in Australia, said more study of long-term effects was needed.

Dr. Halford notes that as more couples meet through Web dating services, the appeal of online couples counseling may increase. “If information technology is integral to how you began your relationship,” he said, “then if therapy is required it’s not surprising that they would look to online technology.”


A version of this article appeared in print on June 29, 2010, on page D1 of the New York edition.