Fragmentation of team-based clinical learning in hospitalized adult care

Over the course of my 8-week Internal Medicine clerkship, the composition of my team changed a total of 8 times. Settling into a smooth team dynamic with a new resident or attending takes at least a few days. Once I got used to working with one set of people, the teams were shuffled around, and I had to restart the process of getting to know a new resident or attending. This instability frustrated me.

Resident work hour restrictions

Why is the system like this? Part of it has to do with resident work hour restrictions, which currently limit residents from working more than 80 hours per week, averaged over 4 weeks. They further restrict interns from working more than 16 consecutive hours and upper-level residents from working more than 24 consecutive hours. Medical students have to follow these restrictions, too. My understanding is that there was much more continuity of team composition, and patient care, before resident work hour restrictions were put in place.

I was talking to one of my residents about this lack of continuity, for medical students and residents alike, and how that takes away from clinical learning. He described how he had taken 30-hour calls with the rest of his team as a third-year medical student; he also agreed with me that medical students get short-changed under the current system.

The way I see it, a solid clinical education, at all levels of training, is very much in the best interest of patient care. So again, why is the system like this? The movement to restrict resident work hours was aimed at increasing patient safety and reducing medical errors due to fatigue. It dates back to the sad case of Libby Zion, a young woman who died after mismanagement by two sleep-deprived residents.

Effects of fatigue on performance

A 1997 study published in Nature reports that being awake for 21 consecutive hours is equivalent to a blood alcohol content of 0.08% (the legal limit for driving). Furthermore, every 0.01% BAC increase was found to correlate with a roughly 1% decline in psychomotor performance on a standardized task, and that correlation was linear.

Before the new work restrictions, residents were ending their 30-hour shift at an equivalent BAC of 0.17%, or more than twice the level at which society has decided that it is unsafe to drive a car. With the new work hour restrictions in place, residents are ending their shift at an equivalent BAC of 0.11%, an improvement, but still over the legal driving limit.

My opinion

Medicine is regarded as a conservative institution for good reason. By graduating from medical school and completing residency, physicians gain a vested interest in the status quo. Institutional change doesn't come easily to medicine, so these new resident work hour restrictions are monumental.

I agree with the restrictions on resident work hours from a theoretical standpoint, and I appreciate them for protecting my future sanity and my future patients' safety. I sure wouldn't want a drunk internist to care for me in the hospital, or a drunk surgeon to operate on me. However, based on my (admittedly limited) two months’ experience with hospitalized adult care, it seems to me that these work hour restrictions have unintended negative consequences, not the least of which is a more fragmented clinical experience for third-year medical students. In trying to balance adequate physician training with work hour restrictions to protect patient safety, there are no easy answers.

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Late update: Several of my colleagues are of the opinion that resident work hour restrictions have less to do with team discontinuity than the mismatch between the schedules of medical students, residents, and attendings.

One person said:

Our M3 rotation cycle doesn't match up with the monthly resident switch, and then the attendings all have 10 days on inpatient straight and then they switch. So our high composition turnover was simply due to the fact that attendings, residents, and medical students all have differing cycle duration through a given team.

Another person agreed, saying:

It is hard enough to line up Residents with each other. Let alone attendings with their resident teams. And, as always, the bottom of the barrel is the medical student who gets last dibs.

I observed the same phenomenon during my Internal Medicine clerkship and agree that it probably more directly led to team discontinuity. However, particularly at Denver Health, it seemed to me that this off-cycle rotation of medical students, residents, and attendings was made worse by a call cycle structured partly as a consequence of resident work hour restrictions.