Work Hour Limits for Medical Residents Spur Otolaryngologists to Rethink Patient Handoffs

In a surgical specialty such as otolaryngology, things “operate in a culture in which the physician has traditionally been available to his or her patients 24/7,” Dr. Philibert said. “There are patient safety and learning benefits in peri-operative continuity that are not fully compensated by good handoffs—particularly if there are post-operative complications where the surgeons who performed the operation are in a better position to provide treatment than another physician, even when armed with complete and accurate handoff information.”

But with current work hour limits, how can physicians make the handoff process both smooth and smart so that patient care isn’t compromised? It’s important to know. According to research published in 2009, 26 to 31 percent of malpractice suits pointed to errors that occurred during the handoff process (Acad Med. 2009;84:1775-1787).

How the System Works and Why There Are Problems

Each otolaryngology program, like programs in other medical specialties, typically has its own method through which its residents learn the handoff process. Currently, universal protocols aren’t in place due to the variables among institutions, said Mark A. Zacharek, MD, a clinical associate professor and associate program director at the University of Michigan Health System’s department of otorhinolaryngology, and director of the Michigan Sinus Center in Ann Arbor.

“Some day we may have a nationally accepted standard by which the patient handoff occurs,” said Dr. Zacharek. “This may be difficult because programs vary in size, geography, size of hospitals and whether a Veteran’s Administration Hospital or Community Hospital systems are part of an otolaryngology training program.”

Such differences also affect how the handoffs take place—whether in person in a group meeting, over the phone via conference call or through online formats such as Skype or Facetime, said Dr. Zacharek.

In a 2012 editorial about the surgical handoff, Dr. Zacharek and colleague Waleed M. Abuzeid, MD, a clinical instructor in rhinology and advanced sinus surgery at Stanford University, wrote that “poorly performed handoffs generate medical errors, increase the length of hospital stays, elevate costs and cause patient harm” (Ear Nose Throat J. 2012;91:460-464).

One way to fix these issues? Supervision is a key component for an effective handoff. “Most programs rely upon the senior/chief residents to closely monitor how junior residents provide hand off information,” said Dr. Zacharek. It is through this method that doctors learn, said Anna Messner, MD, professor, vice chair and residency program director in the department of otolaryngology/head and neck surgery at Stanford University. “I think most residents get good at handoffs over time, so that by the time they finish they are fully competent,” she said. “But one of the ways they get good is that they learn from suboptimal experiences. In my opinion, the best way to speed up the learning process is to have senior residents observe junior residents doing actual handoffs. The senior or chief residents are the best at knowing what information is important, what does not need to be said, where are the potential problems.”