Mar 23, 2018

Flex all day

The story

Every doc who's 10 years your senior will give a "when I was an intern" story within 3 minutes of shaking your hand. So what happens when shift-length limits are tested against your attending's anything-goes paradigm?  

The timeline

The 80-hour workweek seems like ancient history, but it was born into controversy in 2003. Some worried about continuity of care while others thought that hour caps didn't do enough to protect residents from long shifts. In 2011, the ACGME implemented 16-hour shift restrictions for interns. Yet after a trial of surgery residents found minimal differences in satisfaction between those with and without shift limits, the ACGME nixed 16-hour shift restrictions last year even though outcomes from a similar study of medicine residents were pending.

The rules

iCOMPARE randomized 63 internal medicine residency programs to flexible or standard shifts. Both groups had a (wink-wink) 80-hour workweek cap. Standard programs adhered to 16-hour shift caps for interns and 24-hour caps for residents, while flexible programs had no limits on shift length or mandatory time off between inpatient shifts. Outcomes were based on resident responses to year-end surveys.

The findings

Flexible program interns were more likely to be upset with the quality of education, their overall well-being, and the effect of residency on their personal lives than those in standard programs. On the whole, flexible programs did not meet non-inferiority criteria. While interns were more likely to express dissatisfaction with flexible policies on most metrics, program directors (PDs) were more upset with standard policies across every metric surveyed. Keep in mind that PDs designed and led iCOMPARE, and all of the pre-specified trial hypotheses argued that trainees would like flexible policies better.

The takeaway

There’s a lot here that (surprise!) casts program leadership as out of touch with trainee experiences. And while some of the headline summaries of iCOMPARE noted that most trainees were happy with both systems, dissatisfaction rates of up to 30% seen in flexible programs are unacceptable.

Say it on rounds

When it's late March and the wards are still filled with pneumonia 

Blame the snow, but prescription opioids aren't helping. Laboratory and clinical research increasingly tie opioids to immunosuppression. A nested case-control study of 1,200 prescription opioid users in a Tennessee Medicaid database found that users were at 65% greater risk of developing pneumococcal disease compared to matched controls. High and long-acting opioid doses placed users at greater risk.   

When your senior resident offers to pre-round so that you can sleep in

Dream on. But sometimes help does come from unexpected places: a prospective cohort that brought blood pressure (BP) management to the barbershop achieved effective BP control in 64% of black male patrons vs. 12% of controls. The intervention group met with pharmacists who prescribed and adjusted antihypertensive meds at black-owned barbershops throughout the Los Angeles area. Both accessibility and community engagement – participants made posters about their experiences that were hung at barbershops – were identified as key factors in the stunning trial results.

When it's the morning after Match Day, and the smell of alcohol makes your stomach churn

You'll be surprised to learn that ED patients had a different experience. A single-center RCT of 120 ED patients with nausea found that the smell of isopropyl alcohol improved patient nausea scores compared to oral ondansetron (Zofran) alone. Intravenous ondansetron was not tested. If the findings hold in further studies, you may see alcohol aromatherapy as a fast and cheap solution to a common ED complaint. 
Ann Emerg Med

Brush up


Chronic cough affects over 12% of the public and just about everyone in your walk-in clinic. Screen first for common triggers like smoking, meds, environmental exposures, and underlying lung disease, then move on to the big 3: asthma, postnasal drip, and acid reflux. Opt for empiric treatment with inhaled steroids or proton pump inhibitors (PPIs) before ordering additional tests to hunt for rare causes. There is growing conviction in the field that unexplained chronic cough is its own disorder that stems from cough reflex hyper-responsiveness. Expert more research soon.

Get meta

With empiric PPIs in chronic cough. Controlled trials have mostly failed to show efficacy, but a 2013 analysis of 9 trials found a benefit for PPIs in patients with abnormal esophageal acid exposure compared to controls. Since most chronic coughers have normal esophageal acid levels, the data for acid suppression remains underwhelming. 

What your science fiction friends are talking about

Two years after returning from a year spent in space, Scott Kelly's gene expression remains significantly different than his earthbound identical twin.
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