Crash Cart: 24-hour shifts for first year residents, community paramedic practice, and primary care hours


This week: First-year residents are bumping up to 24-hour shifts. Plus, paramedics bring emergency geriatric care to patient’s doorsteps. Join in as our editors discuss the week’s headlines.


The 16-hour shift is ending for first-year doctors

A proposal by ACGME recommends that first-year residents be allowed to work 24-hour shifts. The ACGME said the goal is to “improve the coordination of clinical care by the interns and residents in the teaching environment.” Original Article by The Washington Post.

Jyoti Mahapatra, MD: The ‘latest development’ in balancing patient safety with resident education? This is the drug company equivalent of adding a hydrogen ion to an old drug and marketing it as a revolutionary new treatment. It turns out that reducing resident hours did not improve patient safety and actually increased the risks involved with handoffs. It is not just the number of hours worked but how residents spend those hours that affects education. Currently it means doing more work during less hours, spending a large percentage of the day enslaved to EMRs, and not being able to follow through on a patient’s disease course because of reduced hours and more shift work. Residency is supposed to train new physicians to withstand the rigors of being an attending. However, the elephant in the room is that we are trying to prepare them to be overworked to the point of abuse and increasingly burdened with administrative BS, insurance mandates, protocol and core-measure driven medicine. The problem is not just how we train physicians, it is WHAT we are training them for. Plenty of attendings are chronically sleep deprived that affect patient safety, but no one thinks our hours should be restricted. Recognizing and addressing signs of depression and substance abuse are long overdue, but how about improving the conditions that lead residents and attendings to such devastating consequences in the first place. I have very little problem with extending resident work hours, but I have a huge problem with the toxic environment we are training them to bear.

Nicholas Genes, MD, PhD: I made the argument last year that a resident’s work had fundamentally changed in the EHR era – notes are less reliable, but more work can be done from the call room. So you can argue that it makes sense that ACGME is trying to minimize handoffs, and extend hours. I think that’d be a reasonable argument, for instance, for going from 8 to 12 hours, or 12 to 16. But what other fields are advocating their members work 24-hour shifts? (actually it’s up to 28 hours – read the fine print). It’s not pilots, not air traffic controllers. Not security guards. Maybe in the army, but I understand it’s rare in modern combat situations. I used to be flattered by the idea that residents worked such long hours – because we could, or because it was better for patient care. Now I’m pretty sure it’s just hospital administrators maximizing the cheap labor.


Community paramedic practice can combat the ways in which hospitalization can accelerate older patients’ decline

Community paramedic practices are multiplying across the country for geriatric emergency care due to costs of emergency room visits and the rate of deconditioning from time spent in hospital beds. Original Article by The New York Times.

Jyoti Mahapatra, MD: l would love to know how the patient in the article had an x-ray in her home that showed her hip fracture. Because most of the elderly patients I see are present with falls or generalized complaints like weakness/dizziness. All of them need some form of imaging and/or lab work. I have a hard time believing the quoted study that demonstrated 80% of geriatric patient complaints could be addressed and treated at home instead of the ED. I’ll be the first to acknowledge the dangers of hospitalization and dread the challenging rehab that lies ahead for my geriatric patients. I would gladly avoid hospitalization if patients had the resources and support to manage their condition at home. Obviously they don’t or I wouldn’t be arranging said admission. However, as admits for ‘weaker’ diagnoses become increasingly difficult, I welcome alternatives to access to care as long as they are appropriate and thorough.

Nicholas Genes, MD, PhD: I’m really glad community paramedicine is establishing itself in various locations, and patients and families are seeing how good it can be. It has taken years, but the perverse incentives of payment for transport, and liability concerns, are finally loosening up. Let’s see if efforts like this continue to expand.


Can Primary care physicians help reduce ER wait times?

An English study determined that primary care practices that extended their hours (including nights and weekends) saw a reduction in patients seeking emergency department visits for minor problems. Original Article by Medical Economics.

Jyoti Mahapatra, MD: I know of one primary care practice that offers evening extended hours at multiple locations throughout town. It seems to operate as an urgent care, within a patient’s own PCP system. I believe that a majority of the time patients do not see their own physician or mid-level, just whomever happens to be working that evening. But that is still better continuity of care than someone coming to the ED because their PCP office couldn’t get them in for 2 weeks or the patient cannot make it to an appointment during normal business hours. I wish there were more options like this. I am also curious whether patients without a PCP can be seen at these locations, or only established patients. It would be a huge win if new patients could also be seen and establish care while being treated for their non-emergent complaint.

Nicholas Genes, MD, PhD: For every three slots booked in the extended hours, one ED visit was avoided – that’s great! But this is a British study, and makes it hard to generalize to our population and practices. I’d wonder, how many clinic visits led to an ED workup? As Corey Slovis has said, “the ED is a victim of its own greatness … we work faster and quicker than anyone else … we do a 2-3 day hospital workup in 6-12 hours.” A lot of patients, and clinicians, know this and take advantage of it.

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  1. Gnome De Plume on

    Regarding the upping of hours for residents, it’s just another way of mind control. They do that in the army too. If you look up the ways groups and cults control their converts, there are many parallels here.

  2. Daniel W. Selby EMT-P on

    Community paramedicine can help an often overburdened healthcare system. It no secret that an advancement in educational practices produces a more well rounded provider. I have been a paramedic for over 40 years; that said I have learned so much from the doctors, FNP’s and PA’s I have worked with. that the knowledge gained by professional interactions and teaching can be moved to the living room in many cases. A 75yo, otherwise health female who has an onset of vomiting while downing her gallon of bowel prep for her non-emergent colonoscopy could initially be managed by antiemetic therapy and if necessary IV fluids. A 25 yo patient with an onset of thrush 2 days post initialization of abx for strep throat could receive a dose of Diflucan and follow up with their PCP as needed. I have personally transported these types of complaint more times than I care to remember. Well trained and educated paramedic level providers can assist in the reduction of unwarranted transports and ED overcrowding. Several programs are already in practice. Expansion is indicated. Education and professional oversite are the key.

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