No one wants an exhausted doctor making decisions about their health. That’s why the Accreditation Council for Graduate Medical Education, which is charged with accrediting American medical residency programs, has continued to take steps to limit the time doctors in training spend on the clock. The most recent restrictions, established in 2011, target interns, limiting their work day to no more than 16 hours. It’s a common sense solution to a justified anxiety about fatigued doctors.

Yet the measure may not have been as effective as predicted. A New York Times article surveys emerging literature relating to these changes, and the results may cast doubt on the ultimate effects of hour restrictions. Since the changes, interns have not been getting more sleep, nor are they happier. Evidence suggests the regulations may even be stunting the educational progress of these doctors: interns have actually been spending less time in educational activities, as the time needed for these conferences and lectures contributes to the 16 hour limit on their time.

Patients haven’t been receiving better care, either – no significant improvements in patient care have been reported since the hour limits. One study reveals an increased concern among interns about making medical errors after the change.

The problem with the regulations? Demand for care stays steady, no matter how many hours doctors work, and hospitals haven’t matched this demand by hiring more interns. This means that interns find themselves spread thinner and thinner, as they struggle to complete all their responsibilities with less time to do them. “It’s as if you told airline pilots that they could only work a certain number of hours, but they had to fly 50 percent more flights,” said Dr. Lara Goitein, lead author of a recently published editorial in JAMA Internal Medicine.

Physician fatigue is a very real problem, but efforts to address it should not stop at blanket-level restrictions. Instead, hospitals need to devote money to hiring more doctors in order to ensure that each patient can receive quality care from an engaged and focused professional. There’s no denying that such an effort would result in short-term losses, but the payoffs in better patient care – and, perhaps, outcomes – would likely be well worth it.
-Devon Branin

A recent study has confirmed that methicillin-resistant Staphylococcus aureus (MRSA) is being transmitted from animals to people (NY Times story, and NPR story). While this has long been suspected, the University of Cambridge study uncovered more concrete evidence by studying cases of MRSA in Denmark – a country where a generally low incidence of MRSA means sources for exposure are lower than in the rest of the world. Geneticists were able to compare MRSA samples from both patients and the infected livestock they owned, and discovered a similarity in the genes of the bacteria indicating likely transmission.

These findings highlight warnings issued by those in agricultural public health for years, who have long suggested that the overuse of antibiotics on livestock could pose huge risks for humans. Managers of factory farms have been known to use antibiotics on all animals to encourage growth, a practice which may encourage the development of drug-resistant pathogens. This study demonstrates that these new hard-to-treat germs could easily make people very sick.

The FDA has moved for voluntary action from farms to curb the spread of drug-resistant pathogens, asking those in the food industry to phase out blanket application of antibiotics. Previously, the FDA has pushed for stronger restrictions on antibiotics, partnering with the CDC in a statement condemning the current state of their use in agriculture. However, in 2011, the FDA veered away from efforts to regulate antibiotics, choosing the voluntary path instead.

HCFA has worked extensively with MRSA prevention in hospitals, and this new research poses an additional challenge to those efforts. Farm workers, for instance, who are unaware that they have been infected, may be hospitalized and introduce MRSA to the hospital, risking the health of other patients, especially those with weakened immune systems. With so much at stake, responsible use of antibiotics in animals is essential.
-Devon Branin

The Statewide Quality Advisory Committee met Monday and discussed priorities for the coming year as they prepare to solicit nominations for measures to be considered for the Statewide Quality Measure Set and as they consider experts they would like to bring in to meet with the group.  The SQAC members came to consensus on the need to prioritize patient-centered care and to have a particular focus on behavioral health and coordination of care. The group agreed that behavioral health is an area where there is the potential for the greatest improvement in quality of care and patient-centeredness of care. As part of the larger area of patient-centeredness, the group also talked about looking at measures relating to shared decision-making, patient confidence, and patient-reported outcomes.

We at HCFA are excited that this will be a focus of the group and we look forward to continuing to actively participate in conversations about quality measures and quality improvement activities.
-Deb Wachenheim