New intern schedule

[VA Hopeful Dr]

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I still think the "you need to come up with your own solution" line is a bit if a cop out. Sign outs have been an issue since the 70s. In 40 years nobody has figured out the perfect sign out, if in fact there is one. And since that time residents are carrying more patients, and there are now more sign outs per day. I seriously doubt your sign out system is the ideal, and as Prowler points out, what you describe takes way way way too long for settings with more cross coverage and sicker patients. So what if you have a system that works for a small volume of noncomplicated patients. You are basically saying communism works based on a kibbutz, while ignoring that it does not work in China or the Soviet Union. And I bet more things fall through the cracks even in your perfect system than you'd care to admit or if there were fewer sign outs. I think every system can be tweaked to a point, but when you work on fixing something for 40 years, with a lot brighter minds than you or I, and still have lots of systemic flaws, it might be time to take the view that it might be something that won't ever get a whole lot better. (hence my Mideast comparison).

There is no perfect system that will suit everyone ideally. Medicine is too varied for that (sounds cliched, and you wouldn't think I'd have to spell it out but here we are...).

Of course the way we do things isn't perfect, and I'm sure things do fall through the cracks. That happens during all types of patient care.

Back in the 30 hour call days, did you ever forget to f/u on a lab/xray/ST eval/whatever? I know I did. The question then comes back, as it always does, to which is safer... potentially more things falling through the cracks with increased handouts, or more errors made by exhausted residents. No one yet knows the answer to this.

I do take some issue with the "noncomplicated patients" part, but whatever.

 

[SouthernSurgeon]

There is no perfect system that will suit everyone ideally. Medicine is too varied for that (sounds cliched, and you wouldn't think I'd have to spell it out but here we are...)

I think you are completely right about this. Except I wouldn't limit it to the issue of sign outs.

The requirements of residency training vary greatly by specialty. I think duty hour limitations shouldn't be one size fits all.

 

[Giemsa]

I'm not sure of the specific references, but there have been studies that proved pretty decisively that the error rate for a resident increased as they approached 30 hrs in the hospital.

Anecdotally, the 30-hour mark is when my brain just threw itself down on the floor like a tantrum-y three year old and refused to walk any further. Absolute zombification.

 

[Acherona]

It's still inhumane to make a human being stay awake for 30 hours. I don't care what the error rates are.

I personally much prefer nightfloat to overnight calls. On nightfloat I eventually get used to the night-day switch and treat it as a regular work shift. On calls I'm always hoping/trying to take "naps" so I can stay on a day schedule and also be awake for rounds. It's painful.

 

[deleted103644]

It's still inhumane to make a human being stay awake for 30 hours. I don't care what the error rates are.

I personally much prefer nightfloat to overnight calls. On nightfloat I eventually get used to the night-day switch and treat it as a regular work shift. On calls I'm always hoping/trying to take "naps" so I can stay on a day schedule and also be awake for rounds. It's painful.

It's inhumane to make me wake up at 4:30 every morning. 30 hour shifts with the occasional day sleeping in would be lovely.

 

[turkeyjerky]

It's inhumane to make me wake up at 4:30 every morning. 30 hour shifts with the occasional day sleeping in would be lovely.

I don't see how the two go together

 

[deleted103644]

I don't see how the two go together

They don't really, I'm just complaining. 🙂

 

[cpants]

There is no perfect system that will suit everyone ideally. Medicine is too varied for that (sounds cliched, and you wouldn't think I'd have to spell it out but here we are...).

Of course the way we do things isn't perfect, and I'm sure things do fall through the cracks. That happens during all types of patient care.

Back in the 30 hour call days, did you ever forget to f/u on a lab/xray/ST eval/whatever? I know I did. The question then comes back, as it always does, to which is safer... potentially more things falling through the cracks with increased handouts, or more errors made by exhausted residents. No one yet knows the answer to this.

I do take some issue with the "noncomplicated patients" part, but whatever.

And this is a problem. We don't know. We adopted a new system without first showing that it is better or safer. So much for evidence-based.

 

[deleted103644]

And this is a problem. We don't know. We adopted a new system without first showing that it is better or safer. So much for evidence-based.

It's just lawsuit avoidance - any error caused by a resident at the end of a thirty hour shift would be a guaranteed pay day.

 

[wild0ne]

There are actually quite a few ongoing studies showing the opposite, as johnnydrama suggests. It's anything but "reasonably consistent". This is what is frustrating about ACGME continuing to talk about adjustments to duty hours. After the initial change (to 80 hours), the data didn't show appreciable decrease in errors, and after this more recent change, which is far far too early to evaluate scientifically, the results are very mixed, yet I'd bet ACGME isn't done tinkering.

Would you mind citing these studies? It's easy to keep reiterating "the data" and "ongoing studies" show "the opposite", without actually providing the links.

Here are just a few findings from studies arguing in favor or reducing work hours, all from reputable journals:

1. Make 36% more serious medical errors than those whose scheduled work is limited to 16 consecutive hours;(Landrigan et al, NEJM 2004)
2. Make five times as many serious diagnostic errors;(Landrigan et al, NEJM 2004)
3. Have twice as many on-the-job attentional failures at night;(Lockley et al, NEJM 2004)
4. Suffer 61% more needlestick and other sharp injuries after their 20th consecutive hour of work, exposing them to an increased risk of acquiring hepatitis, HIV, and other blood-borne illnesses;(Ayas et al, JAMA 2006)
5. Double their risk of a motor vehicle crash when driving home after 24 hours of work;(Barger et al, NEJM 2005)
6. Experience a 1.5 to two standard deviation deterioration in performance relative to baseline rested performance on both clinical and non-clinical tasks; (Philibert, Sleep 2006)
7. Suffer decrements in performance commensurate with those induced by a blood alcohol level of 0.05 to 0.10% (Dawson and Reid, Nature 1997; Arnedt et al., JAMA 2005)
8. Report making four times as many fatigue-related medical errors that lead to a patient’s death (Barger et al., PLoS Medicine, 2006).

Despite the evidence (and much more since 2006), proponents of the status quo continue to cite insufficient of inadequate evidence for work hour restrictions. It reminds of Fox News convincing the masses to vote in opposition of their best interests by targeting the ignorant. It's a little embarrassing that people are still arguing about this anymore.

 

[SeekerOfTheTree]

Wow. That was a good informative post.

 

[High Roller]

And this is a problem. We don't know. We adopted a new system without first showing that it is better or safer. So much for evidence-based.

I think this is missing the point.

I'm sure that if we turned the hospital into a medical monastery where residents breathed, ate, and slept medicine and were never allowed home...we'd have the absolute safest system for patients. The problem is that its inhumane. And I understand its unpopular to a thread full of surgery residents to preach about resident wellness, but as a profession, we suck at taking care of ourselves. That should be part of the discussion here too, but I think pride tends to get in the way.

As far as what is safer...lets be honest...we're never going to truly know. Medicine is far too broad and complex to get a definitive answer. I just wish we'd move beyond this discussion, because we're not going back to the old days of endless intern call. Fair or not, the public won't allow it. And it makes us look like we have a god complex when we say that we're just as safe to patients after a 24hr call when study after study says we aren't.

 

[Law2Doc]

And this is a problem. We don't know. We adopted a new system without first showing that it is better or safer. So much for evidence-based.

Exactly. The fact that the ACGME rapidly followed one set of changes with another without showing that the first one actually worked is embarrassing for a supposedly scientific profession.

 

[Law2Doc]

Would you mind citing these studies? It's easy to keep reiterating "the data" and "ongoing studies" show "the opposite", without actually providing the links.

Here are just a few findings from studies arguing in favor or reducing work hours, all from reputable journals:

1. Make 36% more serious medical errors than those whose scheduled work is limited to 16 consecutive hours;(Landrigan et al, NEJM 2004)
2. Make five times as many serious diagnostic errors;(Landrigan et al, NEJM 2004)
3. Have twice as many on-the-job attentional failures at night;(Lockley et al, NEJM 2004)
4. Suffer 61% more needlestick and other sharp injuries after their 20th consecutive hour of work, exposing them to an increased risk of acquiring hepatitis, HIV, and other blood-borne illnesses;(Ayas et al, JAMA 2006)
5. Double their risk of a motor vehicle crash when driving home after 24 hours of work;(Barger et al, NEJM 2005)
6. Experience a 1.5 to two standard deviation deterioration in performance relative to baseline rested performance on both clinical and non-clinical tasks; (Philibert, Sleep 2006)
7. Suffer decrements in performance commensurate with those induced by a blood alcohol level of 0.05 to 0.10% (Dawson and Reid, Nature 1997; Arnedt et al., JAMA 2005)
8. Report making four times as many fatigue-related medical errors that lead to a patient's death (Barger et al., PLoS Medicine, 2006).

Despite the evidence (and much more since 2006), proponents of the status quo continue to cite insufficient of inadequate evidence for work hour restrictions. It reminds of Fox News convincing the masses to vote in opposition of their best interests by targeting the ignorant. It's a little embarrassing that people are still arguing about this anymore.

None of these studies compare error rates between the two systems, which is the real question. Nobody disputes that there are some errors caused by lack of sleep. (there are however numerous criticisms of the article you mentioned above comparing alcohol and many in the industry question how that article even got published -- a more critical reading of that one is recommended). Many of the upcoming studies however dispute that the new system doesnt incorporate more and worse error potentials into the system, with more handoffs etc.there are several in progress studies ( at Hopkins and elsewhere ) which are going to call the ACGME changes into question. You trade one set of errors for a bigger set, based on some of the prelim data.

 

[deleted103644]

Despite the evidence (and much more since 2006), proponents of the status quo continue to cite insufficient of inadequate evidence for work hour restrictions. It reminds of Fox News convincing the masses to vote in opposition of their best interests by targeting the ignorant. It's a little embarrassing that people are still arguing about this anymore.

No one is arguing this.

What some are arguing is that by decreasing a risk factor for individual errors you are increasing the risk of errors due to systemic issues (eg increasingly mangled signouts).

That's a valid concern and has some merit, as despite a proven effect of long shifts on individual error in the hospital, studies have shown no net benefit to the rule change.

I'm sure people are looking at it though, so if you find any studies on it feel free to share.

I'm too tired after working nine days straight to check it myself. 😛

 

[Law2Doc]

...
I'm too tired after working nine days straight to check it myself. 😛

you are well rested according to the ACGME.

 

[gutonc]

What some are arguing is that by decreasing a risk factor for individual errors you are increasing the risk of errors due to systemic issues (eg increasingly mangled signouts).

And this here is really the crux of the issue. It will probably be pretty easy to prove that by decreasing shift length, errors made by Dr. X will decrease.

But that's not really the issue that should be at hand. We should be attempting to decrease the total number of medical errors being made (which I don't think anyone would argue is a bad idea). So the real comparison (which won't be available for another 2 or 3 years) should be "In hospital system X over a 1-2 year period before and another 1-2 year period after changes in work hour rules, did the total number of medical errors that resulted in increased patient LOS, morbidity and mortality change?".

But I will bet you my entire salary for the month of July (NB...I'll be unemployed in July) that this will not be the study that gets published in NEJM or JAMA in 2014.

 

[cpants]

Would you mind citing these studies? It's easy to keep reiterating "the data" and "ongoing studies" show "the opposite", without actually providing the links.

Here are just a few findings from studies arguing in favor or reducing work hours, all from reputable journals:

1. Make 36% more serious medical errors than those whose scheduled work is limited to 16 consecutive hours;(Landrigan et al, NEJM 2004)
2. Make five times as many serious diagnostic errors;(Landrigan et al, NEJM 2004)
3. Have twice as many on-the-job attentional failures at night;(Lockley et al, NEJM 2004)
4. Suffer 61% more needlestick and other sharp injuries after their 20th consecutive hour of work, exposing them to an increased risk of acquiring hepatitis, HIV, and other blood-borne illnesses;(Ayas et al, JAMA 2006)
5. Double their risk of a motor vehicle crash when driving home after 24 hours of work;(Barger et al, NEJM 2005)
6. Experience a 1.5 to two standard deviation deterioration in performance relative to baseline rested performance on both clinical and non-clinical tasks; (Philibert, Sleep 2006)
7. Suffer decrements in performance commensurate with those induced by a blood alcohol level of 0.05 to 0.10% (Dawson and Reid, Nature 1997; Arnedt et al., JAMA 2005)
8. Report making four times as many fatigue-related medical errors that lead to a patient’s death (Barger et al., PLoS Medicine, 2006).

Despite the evidence (and much more since 2006), proponents of the status quo continue to cite insufficient of inadequate evidence for work hour restrictions. It reminds of Fox News convincing the masses to vote in opposition of their best interests by targeting the ignorant. It's a little embarrassing that people are still arguing about this anymore.

First of all, that is a pretty poor cohort of research to base systemic changes upon. Just as an example, study 1 is an unblinded study where nurses identify possible errors and the 'traditional' schedule group works 80 hours/week while the shift-work group works 60 hours/week. The rest of the studies are low quality as well. I hardly see a smoking gun which would cause us to abandon the traditional schedule.

Sleep deprivation causes error. That's common sense. But, if anything, that's just an argument that we should reduce work hours further. Are interns taking weeks of night float really better rested and thus safer than your standard intern? In my experience with both systems, an intern on a week of night float is probably more sleep deprived than one on a traditional call schedule. In the traditional schedule you stay on a basically nocturnal sleep pattern, and after a night shift you get extra time off to catch up.

The elephant in the room is that we are probably understaffed and not using our resources effectively. When I'm up all night taking 50 pages for tylenol orders and antiemetics, I end up tired when a 4am consult comes in and a patient needs my focus on their diagnosis and care. That stuff is important patient care, but it's stuff any intern should master in the first few weeks of internship and not really educational. Maybe we should move to a model where MLP's handle the basics overnight and the intern becomes 'second call' for patients who actually need evaluation (hypotension, chest pain, sob, bleeding, etc.). Sounds expensive.

 

[wild0ne]

As far as what is safer...lets be honest...we're never going to truly know. Medicine is far too broad and complex to get a definitive answer. I just wish we'd move beyond this discussion, because we're not going back to the old days of endless intern call. Fair or not, the public won't allow it. And it makes us look like we have a god complex when we say that we're just as safe to patients after a 24hr call when study after study says we aren't.

Agreed. This is a losing battle for those that continue to argue for unrestricted work hours, in the face of common sense, public opinion, and now, mounting empirical evidence.

 

[wild0ne]

In my experience with both systems, an intern on a week of night float is probably more sleep deprived than one on a traditional call schedule. In the traditional schedule you stay on a basically nocturnal sleep pattern, and after a night shift you get extra time off to catch up.

That's a fairly common, yet uninformed view. Again, your 'experience' is contrary to the evidence:

"Yet many individuals believe they adapt to chronic sleep loss or that recovery requires only a single extended sleep episode." ... ... "Despite recurrent acute and substantial chronic sleep loss, 10-hour sleep opportunities consistently restored vigilance task performance during the first several hours of wakefulness. However, chronic sleep loss markedly increased the rate of deterioration in performance across wakefulness, particularly during the circadian night".

Uncovering Residual Effects of Chronic Sleep Loss on Human Performance. Daniel A. Cohen, Wei Wang, James K. Wyatt, Richard E. Kronauer, Derk-Jan Dijk, Charles A. Czeisler, Elizabeth B. Klerman. Science Translational Medicine, 13 January 2010; Volume 2 Issue 14

The elephant in the room is that we are probably understaffed and not using our resources effectively. When I'm up all night taking 50 pages for tylenol orders and antiemetics, I end up tired when a 4am consult comes in and a patient needs my focus on their diagnosis and care. That stuff is important patient care, but it's stuff any intern should master in the first few weeks of internship and not really educational. Maybe we should move to a model where MLP's handle the basics overnight and the intern becomes 'second call' for patients who actually need evaluation (hypotension, chest pain, sob, bleeding, etc.). Sounds expensive.

Agreed. However, there are strong financial incentives keeping that elephant in the room, as you mentioned. Let's not kid ourselves by saying working obscene hours serves some noble purpose.

 

[wild0ne]

That's a valid concern and has some merit, as despite a proven effect of long shifts on individual error in the hospital,studies have shown no net benefit to the rule change.

Again, simply not true.

"In a systematic review, we found that reduction or elimination of resident work shifts exceeding 16 hours did not adversely affect resident education, and was associated with improvements in patient safety and resident quality of life in most studies."

Effects of reducing or eliminating resident work shifts over 16 hours: a systematic review.
Levine AC, Adusumilli J, Landrigan CP. Harvard Affiliated Emergency Medicine Residency, Department of Emergency Medicine, Brigham and Women's and Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA.

Even the surgical literature is coming around:

"Implementation of RWHR was associated with reduced provider-related complications and mortality suggesting improved patient safety. This was likely due to several factors including reduced resident fatigue and greater attending involvement in clinical care."

Implementation of resident work hour restrictions is associated with a reduction in mortality and provider-related complications on the surgical service: a concurrent analysis of 14,610 patients.
Privette AR, Shackford SR, Osler T, Ratliff J, Sartorelli K, Hebert JC. Department of Surgery, College of Medicine, University of Vermont, Burlington, VT 05401, USA.

We can all argue with anecdotes, experiences, and beliefs until we're blue in the face. The totality of the evidence shows that reducing extended work hours is right for residents and for patients. There are valid points to be made, since the duty hour restrictions are not without consequences. However, it's time to give up some of the tired arguments (i.e., lack of "reasonably consistent" data).

 

[wild0ne]

I still think the "you need to come up with your own solution" line is a bit if a cop out. Sign outs have been an issue since the 70s. In 40 years nobody has figured out the perfect sign out, if in fact there is one. .... I think every system can be tweaked to a point, but when you work on fixing something for 40 years, with a lot brighter minds than you or I, and still have lots of systemic flaws, it might be time to take the view that it might be something that won't ever get a whole lot better.

That's flawed logic. You assume that the resources available to '[fix] something' have remained static.

One of the earliest studies to show that increased handoffs increased the risk of adverse events was performed by Petersen et al in 1994:

Does housestaff discontinuity of care increase the risk for preventable adverse events?
Petersen LA, Brennan TA, O'Neil AC, Cook EF, Lee TH. Brigham and Women's Hospital, Boston, MA.

A subsequent study performed by the same authors four years later found that using computerized sign-out help mitigate those adverse events:

Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Petersen LA, Orav EJ, Teich JM, O'Neil AC, Brennan TA. Career Development Award Program, Veterans Affairs Health Services Research and Development Service, Brockton/West Roxbury Veterans Affairs Medical Center, Massachusetts 02132, USA.

As others have already mentioned, the focus should be on improving handoffs. With technical advancements that allow for improved communication, this is more feasible now than ever before.

Since you prefer Mideast comparisons ... Should we give up on finding alternate fuel sources, since the combustible engine hasn't been improved in 40 years? Or, do you think there are more forces in play than just complexity?

 

[45408]

That's a fairly common, yet uninformed view. Again, your 'experience' is contrary to the evidence:

"Yet many individuals believe they adapt to chronic sleep loss or that recovery requires only a single extended sleep episode." ... ... "Despite recurrent acute and substantial chronic sleep loss, 10-hour sleep opportunities consistently restored vigilance task performance during the first several hours of wakefulness. However, chronic sleep loss markedly increased the rate of deterioration in performance across wakefulness, particularly during the circadian night".

Is your study comparing day time work to being on call, or is it comparing night float to being on call? Because someone has to be there at night, which is what we're all arguing about.

Agreed. However, there are strong financial incentives keeping that elephant in the room, as you mentioned. Let's not kid ourselves by saying working obscene hours serves some noble purpose.

Of course the almighty dollar plays a big role, but working more hours does give you more experience than working fewer hours.

Here are just a few findings from studies arguing in favor or reducing work hours, all from reputable journals:

4. Suffer 61% more needlestick and other sharp injuries after their 20th consecutive hour of work, exposing them to an increased risk of acquiring hepatitis, HIV, and other blood-borne illnesses;(Ayas et al, JAMA 2006)

I felt that what this study actually shows is that more sticks happen during the day, but your overall risk is higher at night, which is when crashing/dying patients come in, and you're likely to be doing something in a hurry. It's going to be the middle of the night either way, and they didn't analyze the risk of anyone on night float (they were all excluded).

Pressure to perform procedures
quickly, which may vary with time of
day and in different specialties, may
have contributed to our findings. Operating
rooms tend to be busier in the
daytime than during the nighttime,
which could account for the increased
rate of injuries in the operating room
in the daytime. In contrast, house staff
on labor and delivery services may be
much busier at night when there are
fewer house staff present; because the
initiation of spontaneous labor usually
peaks at night, this may lead to
more procedures per house staff.

 

[wild0ne]

First of all, that is a pretty poor cohort of research to base systemic changes upon. Just as an example, study 1 is an unblinded study where nurses identify possible errors and the 'traditional' schedule group works 80 hours/week while the shift-work group works 60 hours/week.

That was already addressed by the authors:

"Another important limitation was our inability to blind the medical observers to the schedule of the interns, an issue commonly encountered in investigations of systemic interventions to maximize patients' safety. We addressed this in two ways: first, we instructed observers — none of whom were study investigators — in the importance of consistent, objective detection of serious errors, regardless of study schedule. Second, all initial observations were also reviewed by two independent investigators who were blinded to the study's conditions and who classified incidents with extremely high reliability. Nonetheless, we cannot exclude the possibility that some bias may have resulted from the inability to blind the primary detection process, though our reliability data suggest that this bias was probably minimal."

Limitation? Sure. Deserving of dismissal? Hardly, but if it makes it convenient for arguing, I suppose so.

The rest of the studies are low quality as well.

Again, quite convenient.

 

[45408]

That was already addressed by the authors:

"Another important limitation was our inability to blind the medical observers to the schedule of the interns, an issue commonly encountered in investigations of systemic interventions to maximize patients' safety. We addressed this in two ways: first, we instructed observers — none of whom were study investigators — in the importance of consistent, objective detection of serious errors, regardless of study schedule. Second, all initial observations were also reviewed by two independent investigators who were blinded to the study's conditions and who classified incidents with extremely high reliability. Nonetheless, we cannot exclude the possibility that some bias may have resulted from the inability to blind the primary detection process, though our reliability data suggest that this bias was probably minimal."

Limitation? Sure. Deserving of dismissal? Hardly, but if it makes it convenient for arguing, I suppose so.

Again, quite convenient.

What's convenient is saying "bias was probably minimal."

 

[wild0ne]

Is your study comparing day time work to being on call, or is it comparing night float to being on call? Because someone has to be there at night, which is what we're all arguing about.

Debating the merits of studies is warranted. Denying their existence or dismissing them altogether is ridiculous. As was mentioned, more knowledgeable folks than you and I are working on this...

The study was cited to show that 'catching up on sleep' is a fallacy. It was not designed to compare service models, as the subjects were in controlled environments and not residents.

Of course the almighty dollar plays a big role, but working more hours does give you more experience than working fewer hours.

Studies are already showing that reducing this 'experience' is not having a negative impact on resident education or patient outcomes. So, more is not necessarily better. Less may not be either. But, at the very least, it's more humane. The challenge is finding a better balance, which is what we're all moving towards.

 

[wild0ne]

What's convenient is saying "bias was probably minimal."

No, there's nothing convenient about backing up your statements with evidence, from which a reasonable conclusion can be drawn:

"We evaluated the reliability of the primary data-collection process by conducting dual direct observation for a total of 10 patient-days; there was 82 percent agreement between independent observers with respect to the occurrence of a serious medical error. "

Dismissing studies by broadly stating they're "poor quality" is convenient. As is simply saying data don't exist when they do.

 

[45408]

Debating the merits of studies is warranted. Denying their existence or dismissing them altogether is ridiculous. As was mentioned, more knowledgeable folks than you and I are working on this...

The study was cited to show that 'catching up on sleep' is a fallacy. It was not designed to compare service models, as the subjects were in controlled environments and not residents.

Speaking of fallacies, you just appealed to authority.

Studies are already showing that reducing this 'experience' is not having a negative impact on resident education or patient outcomes. So, more is not necessarily better. Less may not be either. But, at the very least, it's more humane. The challenge is finding a better balance, which is what we're all moving towards.

I'd like to see the studies that show that less experience has no impact on resident education or patient outcomes.

No, there's nothing convenient about backing up your statements with evidence, from which a reasonable conclusion can be drawn:

"We evaluated the reliability of the primary data-collection process by conducting dual direct observation for a total of 10 patient-days; there was 82 percent agreement between independent observers with respect to the occurrence of a serious medical error. "

It's most certainly convenient, and I don't think the conclusion is reasonable. I'm also thoroughly underwhelmed with 82% agreement.

 

[wild0ne]

I was initially confused by your reference to appealing to authority. Fortunately, you provided an example:

It's most certainly convenient, and I don't think the conclusion is reasonable. I'm also thoroughly underwhelmed with 82% agreement.

Anyways, I've provided links to anyone interested in reading further about the subject. Since I'm in a specialty with humane hours, I have to time to go read about our new health care law(s)!👍 Listen, we're all on the same team. No hard feelings. You and the others have good points. Sorry if I was abrasive some of my posts.

 

[Substance]

A large number of your citations come from a single system which raises the question of whether this institution simply has a bias and are publishing studies that promote this opinon.

Leave it to the rad onc to find the most relevant point in a bunch of papers.

 

[RadOncDoc21]

Leave it to the rad onc to find the most relevant point in a bunch of papers.

haha... way to go! 👍

 

[cpants]

That was already addressed by the authors:

"Another important limitation was our inability to blind the medical observers to the schedule of the interns, an issue commonly encountered in investigations of systemic interventions to maximize patients' safety. We addressed this in two ways: first, we instructed observers — none of whom were study investigators — in the importance of consistent, objective detection of serious errors, regardless of study schedule. Second, all initial observations were also reviewed by two independent investigators who were blinded to the study's conditions and who classified incidents with extremely high reliability. Nonetheless, we cannot exclude the possibility that some bias may have resulted from the inability to blind the primary detection process, though our reliability data suggest that this bias was probably minimal."

Limitation? Sure. Deserving of dismissal? Hardly, but if it makes it convenient for arguing, I suppose so.



Again, quite convenient.

Oh wow...that explanation really made me feel better. Do you understand the concept of blinding? It's pretty useless to have the reviewers blinded when the detectors are not. It's poor study design, and it makes the data a lot less credible.

Anyway, that's not even the most silly part of the design. They are comparing a group working 80+hours to one working 60ish. Don't you see a little problem there in drawing a conclusion that the shift length explains the difference in error rate? The control group working about 30% more hours than the experiment group couldn't explain some of their findings?