When one of my best friends in medical school returned from an interview for a surgical residency program, he told me how some of the surgeons there bragged that they were worked so hard that the divorce rate among their trainees was greater than 100 percent — some of them burned through two marriages.

They were proud of this. I was horrified.

I doubt this statistic was true, even 20 years ago, and I’m even surer it’s not true now. But it points to an important truth: Some physicians equate “suffering” with “commitment” and believe that a residency should be grueling and difficult.

A resident is a physician having further on-the-job training after medical school. When I was one, I regularly worked 80-plus hours a week. When I was in the Infant Intensive Care Unit, I was on q3, meaning that in addition to working 12-hour days, I worked every third night between them as well. In a bad week, I could easily work more than 90 hours. And I was a pediatrician. Many specialties, like surgery, have it far worse.

Personally, I couldn’t believe this was good for patient care. Others agreed. In 2003, the Accreditation Council for Graduate Medical Education passed new regulations that capped resident hours at 80 hours per week, and also limited shift lengths and required time off between shifts. In 2011, these were strengthened to further limit the time that interns, or first-year residents, could work.

There are other people in the health care industry who believe that such changes are bad for patient care. Reducing hours and shortening shifts means that doctors have to hand off patients to one another more regularly. Things could get missed. Doctors who are coming on might not understand the patients as well as those who are coming off. Perhaps reducing work hours is bad for patients.

Most evidence does not support this claim. A systematic review found that patient health did not improve after duty hours were restricted, but few studies found that it worsened.

Beyond patient health, there have been concerns that reduced hours might result in worse education. Residents with reduced hours would miss lectures. Surgical residents might be forced to leave procedures. These concerns make sense, but most evidence doesn’t support the claim that education is being harmed either.

A recent study published in the New England Journal of Medicine brings us new answers. This was a national study of 117 general surgery residency programs in 2014 and 2015. Programs were randomized to one of two work-hour policies. The first was “traditional”: Interns could not work more than 16 hours straight. Other residents could not work more than 28 hours straight (24 for “work” and 4 for “transition”).

All residents had to have at least eight (but preferably 10) hours off between shifts, 14 hours if they’d just worked a 28-hour shift. Residents couldn’t work on average more than 80 hours a week over four weeks. They had to have one full day off every seven days over four weeks, and they couldn’t be on call more than every third night.

The other group was assigned the new “flexible” policy. In that one, interns could work more than 16 hours straight, and residents could work more than the 24/28 hours straight. They weren’t required to have the 8 to 10 hours off, or the 14 hours off after a long shift. They still couldn’t work more than 80 hours a week averaged over four weeks, however. They still had to have one day off for every seven, and they still couldn’t be on call more than once every third night. In other words, residents in the “flexible” policy still had maximum hours capped and days off required, but could work longer hours per shift to avoid missing procedures or having to hand off patients if they didn’t want to.

Data were analyzed on almost 139,000 patients. The rates of death and/or serious complications were 9.1 percent in the flexible-policy group and 9 percent in the standard-policy group. The flexible-policy group was not inferior. The concerns we might have about patients being hurt if doctors worked longer shifts do not appear to be well supported by data, at least using these criteria as “hurt.”

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What about satisfaction? Of the 4,330 residents studied, 11 percent of the flexible-policy group and 10.7 percent of those in the standard-policy group reported dissatisfaction with the overall education, essentially no difference. With respect to well-being, almost 15 percent of those in the flexible-policy group and 12 percent of those in the standard-policy group reported dissatisfaction. Again, hardly a difference. Moreover, residents in the flexible-policy group were less likely to report negative effects of duty-hour policies on patient safety, continuity of care, professionalism and resident education. They were also less likely to have to leave in the middle of an operation (7 percent vs. 13.2 percent) or to report having to hand off patients in the middle of continuing problems (32 percent vs. 46.3 percent).

The flexible-policy doctors were, however, more likely to report negative effects on personal activities.

The authors’ conclusions gave me the impression that since giving residents more flexibility, like working longer shifts, did not increase complication rates and seemed acceptable to residents, the complaints of those who demand that residents be protected are overblown. We should let them work more and not interfere. It’s safe and feasible.

I’m not sure I agree. Another way to look at this is that holding residents to relatively shorter shifts didn’t result in higher rates of death or complications in patients either. Given that there don’t appear to be patient harms, the only reason to switch is because you believe it’s better for residents. It’s hard to imagine that’s true.

Further, asking the residents what they think may not be the best way to determine if that’s the case. Residency programs have a way of indoctrinating new recruits into believing that misery is somehow noble.

A better metric, and one that we should all care about, is whether resident surgeons are less well trained and skilled when they come out of residency now than before. I’ve heard plenty of anecdotes to support this notion from colleagues, but I’ve seen no good evidence to prove it. Without good data, it feels more like the usual griping each generation seems to have about being the last great one.

The concerns of those training physicians are valid and should not be ignored. However, if patients aren’t harmed and education doesn’t suffer, we should probably err on the side of treating our doctors-in-training as benignly as possible. As I’ve discussed before, depression and other mental health problems are already common enough during training. We want to be sure that as we create doctors, we aren’t sacrificing human beings.

source: nytimes

Massachusetts—like the rest of the nation—is in the grip of a public health crisis involving opioid overdoses. In 2014, more than 4.6 million scripts for opioid analgesics were written in the Bay State, and an estimated 1,256 people died from heroin and prescription opioid overdoses—the highest number on record. Nationwide, the Centers for Disease Control and Prevention says that the rate of overdose deaths has increased 200 percent since 2000, echoing a 140 percent increase in opioid prescriptions since the mid 1990s.

In an effort to address the opioid overdose crisis in Massachusetts, Governor Charlie Baker reached out this past fall to the deans of the commonwealth’s four medical schools (BU School of Medicine, Harvard Medical School, Tufts University School of Medicine, and University of Massachusetts Medical School) and asked for their help in designing a list of core competencies needing to be covered during medical school to help combat prescription drug misuse, addiction, and overdose fatalities.

Working with the Massachusetts Medical Society and Monica Bharel (MED’94), the commonwealth’s public health commissioner, the schools developed a list of 10 competencies that will be introduced into their curricula beginning this year.

“These educational standards represent an innovative and forward-thinking contribution to the state’s multifaceted strategy to curb the opioid epidemic,” Baker noted in his announcement of the results of the med schools’ collaboration.

“We previously provided a curriculum that emphasized preventing and treating addiction,” says Karen Antman, MED dean and provost of the Medical Campus. “Now we have integrated the 10 competencies over the four years of our curriculum. We are responding to provide a stronger foundation for tomorrow’s physicians and scientists.”

MED’s Safe Opioid Prescribing Curriculum is being overseen by Daniel Alford (SPH’86, MED’92), a MED associate professor of medicine and assistant dean for continuing medical education. The 10 core competencies, centered around 3 major areas, are designed to provide a broader, more comprehensive approach “to understanding the physician role in preventing, screening for, and managing unhealthy substance use and prescription drug misuse in our patients,” Alford says.

“The first area focuses on prevention of this problem in the first place,” he says. “It’s emphasizing the use of multimodal treatments for chronic pain that minimize the use of opioids, or when opioids are indicated, to prescribe them in a way that’s safe and that follows guideline-based care.” Students will be taught to identify those patients who may be at higher risk for running into problems with these medications, including people who have a personal or family history of a substance use disorder and those with a history of mental illness. “It doesn’t mean that you shouldn’t ever prescribe opioids for those individuals,” Alford says. “But it means that they’re at a higher risk for prescription opioid misuse and they need to be informed about that risk and we need to monitor them more closely.”

The second area focuses on patients who have been identified as at risk for developing problems with prescription opioids. The expanded curriculum will teach students how to treat patients who have a history of substance use disorder in a way that accounts for that risk, Alford says, “so that you can decrease the likelihood that the patient in recovery will relapse to active drug use.”

The third area will teach medical students how to manage substance abuse disorders as a chronic disease. This means learning to talk to patients about treatment options (including using motivational interviewing to help patients adopt healthier behaviors) and guiding them to resources and evidence-based treatments.

The new curriculum will be woven throughout the students’ education. The first year they will be taught how to become comfortable asking patients about substance use in a nonjudgmental way and using validated questions so that patients feel comfortable answering honestly.

“This is going to be integrated much like the existing curriculum around nutrition and evidence-based medicine,” says Alford. “There’s no one department that owns it by itself, but it crosses all the various departments, with the curricula imbedded in multiple places.”

As well as lectures and workshops on the neurobiology of addiction and how to screen patients for unhealthy substance use, students will participate in simulations, where they will work with actors playing patients who are suffering from various substance use disorders.

“We really want our students to carefully listen to their patients, to what they say and what they don’t say, and to treat their patients’ pain responsibly,” says Douglas Hughes, Ramsey Professor of Theory and Practice and MED associate dean for academic affairs. “It’s so important they get it right.”

In addition to the new safe prescribing curriculum, all fourth year MED students will complete the two-hour Safe and Competent Opioid Prescribing Education (Scope of Pain) program, a continuing medical education course for physicians and nurses designed by Alford and based on a curricular blueprint created by the US Food and Drug Administration. SCOPE of Pain debuted as an online course in 2013, with live training offered about six months later.

SCOPE of Pain is broken into three modules that follow a fictional female patient already taking opioids for her chronic pain when she visits her new doctor. In the first module, health care providers learn how to assess the patient’s pain and function and her risk for opioid misuse. In the second module, the patient returns a week later and the doctor must decide whether to continue, modify, or discontinue the opioids she’s taking, and if continued, how to monitor her to so she gets the most benefit and the least harm. In the final module, the patient shows up at an emergency room months after her first visit—she’s run out of her prescription and is asking for an early refill. That scenario helps physicians assess the kind of worrisome behavior she’s exhibiting: they need to consider all of the possible causes (differential diagnoses) and figure out how they might talk to her about the risk she’s facing. It also gives them a chance to consider how they might change the patient’s treatment plan. Alford says the program really aims to answer “how do you prescribe opioids in a way that maximizes benefit and minimizes harm.”

An evaluation of the SCOPE of Pain program was recently published in the journal Pain Medicine, showing how the program successfully shifted physician opioid prescribing practice toward safe guideline-coordinate care.

While he is optimistic that initiatives like the new Safe Opioid Prescribing Curriculum will help to reduce the opioid misuse epidemic, Alford, who was just named this year’s recipient of the American Society of Addiction Medicine’s Educator of the Year award, says faculty as well as students need to be trained. “You can train students to know what the right thing to do is, but if they don’t see it modeled when they start doing their clinical rotations, if they go out in the community and they see some doctor who’s doing something completely different, it doesn’t reinforce this new approach,” he says. “It all needs to happen at the same time, but once that occurs, I think we will make a difference.”

Hughes concurs that training tomorrow’s physicians by itself won’t make the opioid crisis go away. “I think this expanded curriculum will be successful in reducing opioid addiction and overdose, but there are bigger forces at play here,” he says. “There is a population of people who have a difficult time finding a job, holding a job. They don’t have opportunities, they don’t have financial resources. And that precipitates trouble. We will deal with the opioid crisis, but there are social inequities that have to be addressed if we’re to really tackle opioid addiction and overdose.”