Letters

evaluate reports of increased risk of pancreatitis and precancerous lesions with incretin mimetic drugs. Adequately powered postmarketing safety studies to address the risk of pancreatic cancer with these agents are urgently needed. The sponsors of all GLP-1–based therapies also need to make patientlevel data from all clinical trials of GLP-1 drugs to an independent entity so that an adequately powered independent metaanalysis of clinical trials can provide additional information on this public health concern. Future observational studies using other designs to evaluate the consistency of these risks in other databases with access to laboratory records and clinical details should evaluate the specific the timing of the hazard and the dose-responsiveness of this association.

The American Medical Student Association supports these efforts, as well as extension of the intern duty hour to upperclass residents. The fact still remains that after a 24-hour shift, cognitive psychomotor performance decreases to a level equivalent to the performance deficit observed at a blood alcohol concentration of roughly 0.10%.2 Pilots are regulated by their profession to fly in 8-hour shifts. We believe that operating on a patient, ordering potentially lethal medications, and performing procedures should be considered at least as equally important to maintain safety due to fatigue. We also encourage further evidence-based studies that look at an integrated approach to reducing duty hours and improving patient care. Aliye Runyan, MD

Sonal Singh, MD, MPH Author Affiliation: Department of Medicine and the Center for Public Health and Human Rights, Johns Hopkins University Schools of Medicine and Public Health, Baltimore, Maryland. Corresponding Author: Sonal Singh, MD, MPH, Department of Medicine and the Center for Public Health and Human Rights, Johns Hopkins University Schools of Medicine and Public Health, 624 N Wolfe St, E 7144, Baltimore, MD 21205 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Singh S, Chang HY, Richards TM, Weiner JP, Clark JM, Segal JB. Glucagonlike peptide 1-based therapies and risk of hospitalization for acute pancreatitis in type 2 diabetes mellitus: a population-based matched case-control study. JAMA Intern Med. 2013;173(7):534-539. 2. Monami M, Dicembrini I, Martelli D, Mannucci E. Safety of dipeptidyl peptidase-4 inhibitors: a meta-analysis of randomized clinical trials. Curr Med Res Opin. 2011;27(S3)(suppl 3):57-64. 3. Singh S, Loke YK. Drug safety assessment in clinical trials: methodological challenges and opportunities. Trials. 2012;13:138. 4. Garg R, Chen W, Pendergrass M. Acute pancreatitis in type 2 diabetes treated with exenatide or sitagliptin: a retrospective observational pharmacy claims analysis. Diabetes Care. 2010;33(11):2349-2354. 5. Butler AE, Campbell-Thompson M, Gurlo T, Dawson DW, Atkinson M, Butler PC. Marked expansion of exocrine and endocrine pancreas with incretin therapy in humans with increased exocrine pancreas dysplasia and the potential for glucagon-producing neuroendocrine tumors. Diabetes. 2013;62(7):2595-2604. 6. Food and Drug Administration. Drug Safety Communication: FDA investigating reports of possible increased risk of pancreatitis and pre-cancerous findings of the pancreas from incretin mimetic drugs for type 2 diabetes. March 14, 2013. www.fda.gov/Drugs/DrugSafety/ucm343187.htm. Accessed June 2, 2013.

Duty Hour Reform: Only a Small Piece of a Larger Problem To the Editor While we acknowledge the need for evidencebased work hour reform, we would point out that the recent study on duty hours1 only addresses a small portion of the larger dynamic at work that contributes to medical error and intern and resident quality of life. Integrated efforts by medical schools and teaching hospitals to address issues such as emotional burnout, better handoff techniques, and interprofessional communication are necessary to further a safe environment for both physicians and patients alike. It is not likely that depression scores will decrease, or patient safety will improve, until the residency training process is addressed in a systematic fashion, eg, more support staff, trainings on culture of medicine and breaking down reporting hierarchies, time for reflection and improvement, and better handoff training. 1844

Author Affiliation: American Medical Student Association, Sterling, Virginia. Corresponding Author: Aliye Runyan, MD, Education and Research Fellow, American Medical Student Association, 21855 Locomotive Terr, Sterling VA 2016 ([email protected]). Conflict of Interest Disclosures: Dr Runyan is employed by the American Medical Student Association. 1. Sen S, Kranzler HR, Didwania AK, et al. Effects of the 2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study. JAMA Intern Med. 2013;173(8):657-663. 2. Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature. 1997;388(6639):235.

In Reply We agree with Dr Runyan that addressing interprofessional communication and handoff training are critical factors in achieving meaningful improvement in both the quality of care that residents provide and the quality of life that they enjoy. Evidence from multiple studies indicate that the most recent set of Accreditation Council for Graduate Medical Education duty hour reforms, which focused almost exclusively on reducing maximum shift length, have not achieved the intended improvements in quality of care or quality of life.1-3 If this experience with interns is instructive, then extending work hour limits to all residents, without addressing the additional factors raised be Dr Runyan, will likely be ineffective. In addition to communication training, an essential piece of the puzzle not addressed by existing duty hour reforms is work compression. House officers now spend fewer hours in the hospital, but their clinical workload and educational requirements have not decreased proportionally, resulting in an even more frenetic pace of work—a phenomenon known as “work compression.”4 In 2000, a typical call day lasted 36 hours. This was specifically reduced for interns from 36 hours to 30 hours in 2004 and to 16 hours with the latest duty hour changes. As a result, current interns have fewer hours to complete their work and engage in learning and team-building experiences. This leaves the new intern generation in a frustrating situation where they are often criticized or chided for having less work when, in many cases, they are simply given less time to complete it. If we know that timed tests result in more errors than untimed ones, we should not be surprised that giving interns less time to complete the same amount of work would adversely affect their patient care. Paradoxically, with the addition of new, often untested, educational curriculum in communication skills and systems of care to traditional clinical topics, interns are also being asked

JAMA Internal Medicine October 28, 2013 Volume 173, Number 19

Downloaded From: http://archinte.jamanetwork.com/ by a Ndsu Library Periodicals User on 06/09/2015

jamainternalmedicine.com

Letters

to learn more in less time. Collectively, these changes often result in reduced opportunities to double-check orders, follow a disease course, spend time at the patient’s bedside, teach students, or share a meal with their team. Incorporating solutions that address the problems associated with work compression are needed to fully achieve the goals of residency duty hour reform. Srijan Sen, MD, PhD Breck Nichols, MD, MPH Aashish K. Didwania, MD Author Affiliations: Department of Psychiatry, University of Michigan, Ann Arbor (Sen); Department of Pediatrics, Keck University of Southern California (USC) School of Medicine, Los Angeles County + USC Medical Center, Los Angeles (Nichols); Department of Medicine, Keck USC School of Medicine, Los Angeles County + USC Medical Center, Los Angeles (Nichols); Department of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (Didwania). Corresponding Author: Srijan Sen, MD, PhD, Department of Psychiatry, University of Michigan, 109 Zina Pitcher Pl, 5047 BSRB, Ann Arbor, MI 48109 ([email protected]). Conflict of Interest Disclosures: None reported. Funding/Support: The project was supported by the grants UL1RR024986 from the National Center for Research Resources (Dr Sen) and MH095109 from the National Institute of Mental Health (Dr Sen). 1. Drolet BC, Christopher DA, Fischer SA. Residents’ response to duty-hour regulations—a follow-up national survey. N Engl J Med. 2012;366(24):e35. 2. Desai SV, Feldman L, Brown L, et al. Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: a randomized trial. JAMA Intern Med. 2013;173(8):649-655. 3. Sen S, Kranzler HR, Didwania AK, et al. Effects of the 2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study. JAMA Intern Med. 2013;173(8):657-663. 4. Ludmerer KM. Redesigning residency education—moving beyond work hours. N Engl J Med. 2010;362(14):1337-1338.

The “New Normal” To the Editor We commend Desai et al1 for their thoughtful comparison of the impact of the 2011 regulations with the initial 2003 Accreditation Council for Graduate Medical Education– implemented duty hour restrictions.2 The authors have demonstrated that, despite overall increase in trainee sleep duration, the educational aspect of training, such as attendance at daytime conferences, is suffering along with the quality of care provided secondary to discontinuity. They conclude with the recommendation of exploration of new models of training, specifically the structural aspect of how the training is designed. In designing systems to comply with duty hours, we should no longer attempt to shoe-horn old educational models into hourlimited training systems and instead explore the reclamation of educational time within training, embrace alternative educational models, and support programs to ease to the transition from undergraduate to graduate medical education. Prior work has demonstrated that, despite duty hour limitations, the workload that trainees face has not decreased3 and up to onethird of residency activity is of limited educational value.4 Mobile technology can also be used to enhance resident efficiency.5 Given the inherent need for off-hour shifts in many new systems, educational models need to evolve to adapt to not only varying levels of the learner, but also the availability of the jamainternalmedicine.com

learner. Online learning platforms have been used with great success in education, and their inclusion in residency training will require the understanding that education can indeed take place independently, not in real-time in a conference room, and still be of value. Finally, one must consider that it is not only the number but the quality of handoffs. More importantly, not all handoffs are created equal. Systems can be designed to maximize continuity despite handoffs through the use of intrateam handoffs by having team members work serially so that someone from the team is always present and has both knowledge of and professional responsibility to the patient. This is in contrast to interteam handoffs, when all members on a team work in tandem; when they leave and handoff, no one who has primary knowledge of the patient is left. Together, we must accept that the “new normal” will require novel ideas and approaches as opposed to tweaking the old system. Jeanne M. Farnan, MD, MHPE Vineet M. Arora, MD, MAPP Author Affiliations: Section of Hospital Medicine, University of Chicago and Pritzker School of Medicine, Chicago, Illinois (Farnan); Section of General Internal Medicine, University of Chicago and Pritzker School of Medicine, Chicago, Illinois (Arora). Corresponding Author: Jeanne M. Farnan, MD, MHPE, Section of Hospital Medicine, University of Chicago and Pritzker School of Medicine, 5841 S Maryland Ave, AMB W216, MC 2007, Chicago IL 60637 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Desai SV, Feldman L, Brown L, et al. Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: a randomized trial. JAMA Intern Med. 2013;173(8):649-655. 2. Nasca TJ, Day SH, Amis ES Jr; ACGME Duty Hour Task Force. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3. 3. Arora VM, Georgitis E, Siddique J, et al. Association of workload of on-call medical interns with on-call sleep duration, shift duration, and participation in educational activities. JAMA. 2008;300(10):1146-1153. 4. Boex JR, Leahy PJ. Understanding residents’ work: moving beyond counting hours to assessing educational value. Acad Med. 2003;78(9):939-944. 5. Patel BK, Chapman CG, Luo N, Woodruff JN, Arora VM. Impact of mobile tablet computers on internal medicine resident efficiency. Arch Intern Med. 2012;172(5):436-438.

In Reply We thank Drs Farnan and Arora for their thoughtful letter. The responses residency programs have had to current duty hour limitations and the consequent work compression have far-reaching effects on the trainee and patient experience, including education and transitions of care. Our study only measured a few of the important short-term outcomes of the 2011 duty hour restrictions. We agree that the “new normal” will require “novel ideas and approaches” and believe we must demand scholarly evaluation of all important changes, using meaningful outcomes, to ensure that any interventions will allow us to produce competent internists and provide excellent and safe health care delivery. Curricular innovation should maximize spontaneous and structured patient-centered learning. For example, senior trainees and faculty should have coaching to develop teaching skills for the 1- to 3-minute lesson. In addition, substantial and effective use of modular, trainee-directed learning must be developed. Many programs have started using online and mobile technologies; howJAMA Internal Medicine October 28, 2013 Volume 173, Number 19

Downloaded From: http://archinte.jamanetwork.com/ by a Ndsu Library Periodicals User on 06/09/2015

1845

Duty hour reform: only a small piece of a larger problem--reply.

Duty hour reform: only a small piece of a larger problem--reply. - PDF Download Free
55KB Sizes 0 Downloads 0 Views