As you may have gathered from various television dramas, medical residents work insane hours. A typical shift “on call” often means 30 straight hours on duty at the hospital, mostly spent on the time-intensive process of admitting new patients. People outside the medical profession often ask why such marathon shifts are necessary, and express surprise when limitations on resident work hours are met with resistance from those very residents. The answer lies in the process that occurs at the end of that shift, a process that becomes more frequent every time resident hours are restricted: hand-offs.
In an ideal hand-off, the end-of-shift resident meets with a fresh resident just starting their workday and relays any information they think the new resident might need about patients admitted overnight. That description stresses the word “ideal” – hospitals are not the quietest environment, and distractions and general mayhem can reduce the hand-off process to a few rushed minutes or eliminate it altogether. Thus, important information about how the new resident should deal with any urgent medical issues that should arise in unfamiliar patients can be poorly communicated, or lost entirely.
Thus, limiting resident work hours may lead to fresher residents, but the miscommunication inherent in increased hand-offs are a consequence of those restrictions, said Vineet Arora, an assistant professor of medicine at the University of Chicago Medical Center who researches patient hand-offs.
“You could have concerns about either a tired physician who knows the patient or a well-rested physician that may not know the patient,” Arora said. “The trade-off is between fatigue and familiarity.”
Just how steep a trade-off that can be was revealed by Arora’s latest paper, part of a collaboration with Boaz Keysar, professor of psychology and an expert on communication. Published this month in the journal Pediatrics, the study examined just how much information is successfully passed between pediatric interns (first-year residents) during hand-offs at Comer Children’s Hospital. After the hand-off, each intern was asked separately what they thought were the most important pieces of information passed along about each patient, the rationale for those decisions, and a rating of how they thought the hand-off went.
The results were worrisome, particularly given that hand-off conditions at Comer, with a distraction-free room provided for physicians to discuss patients as shifts change over, far exceed those found at most hospitals. Even in those optimal conditions, Arora and Keysar (with Vivian Chang, and Shiri Lev-Ari, and Michael D’Arcy) found that what the end-of-shift intern judged as the most important piece of information was not successfully communicated to the new intern more than half the time. The rationale for that information – such as why a patient is on a particular antibiotic – also slipped through the cracks in the majority of cases, with the two interns disagreeing on the rationale in 60 percent of the interviews.
And to pile on the worry, interns rated their hand-offs as high-quality, even while miscommunication was rampant. That disconnect between what a person thinks they’re communicating and what they’re actually getting across to the listener is a common phenomenon, Keysar said.
“You would imagine the kind of miscommunication we discover elsewhere actually might be reduced when the stakes are high in a clinical setting, because it matters so much,” Keysar said. “But the opposite is true, which I think is counter-intuitive and important to know.”
So let’s ban hand-offs, right? Well, unless medical schools begin training their students to go for weeks without sleep, that’s not going to happen. A slightly easier solution would be for med schools to spend more time training future doctors how to conduct a successful hand-off. But it remains unclear what would make for better hand-off communication, Arora and Keysar said. One trick that seemed to work in their study: to-do items and if-then advice that explicitly give the incoming intern instruction about what to do with a patient should action be required.
“We called it anticipatory guidance. You would say, if the following happens, if this patient does this, I need you to do the following,” Arora said. “Those items are more likely to be recalled than knowledge items, than ‘Mrs. Smith had a chest x-ray today and this is what it showed.’”
The importance of information beyond the details is a reason why the communication issues of hand-offs will not be solved with technology, Arora said. Though many hospitals are now equipped with electronic medical records that allow physicians instant access to patient information, hand-offs confer the somewhat intangible ability to act quickly upon that information if the patient’s status changes.
“We aren’t at the point where computers are going to do that for us,” Arora said. “Technology solutions can help so that you have the information that you need when you need it, but to look at that information and be able to make a judgment about what to do, that is what the hand-off conversation is for.”
But as improved educational efforts are just getting started, whispers of further reductions in resident work hours are circulating through the medical community. The 80-hour work limit put in place in 2003 would remain in place, but the Institute of Medicine recommends adding a 16-hour shift limit, or mandatory 5-hour nap periods in the middle of 30-hour overnight call shifts. That would obviously push the number of hand-offs even higher – a consequence that should be considered before new regulations are established.
“We tend to be very myopic in the way we think about this problem,” Keysar said. “Reducing hours is good, but there’s a cost that is not obvious at all, and this study really spells that cost out. It’s very difficult for us to gauge how well we are understood, and this should be taken into account in the trade-off between number of work hours and fatigue.”
Chang, V., Arora, V., Lev-Ari, S., D’Arcy, M., & Keysar, B. (2010). Interns Overestimate the Effectiveness of Their Hand-off Communication PEDIATRICS, 125 (3), 491-496 DOI: 10.1542/peds.2009-0351