affect resident education and was associated with improve-ments in patient safety and resident quality of life in moststudies (3).

It is also important to recognize that “one size does not fitall.” Although a majority of our residents perceive the shortcall system as a blessing, a minority sees little advantage inthe new system. The literature shows that not everyone agreesthat the new duty-hour restrictions are good for patient care oreducation (7, 8). With the ever-increasing demands for clin-ical service, with fewer resources, and frequent restructuringwithin hospital programs, residency programs need to bevigilant about the well-being of residents, without compro-mising their clinical learning and service. Resident feedbackafter any implemented duty-hours change can be an impor-tant tool for programs tomonitor the impact of the policies onresidents. A strength of our study is that the respondents hadexperienced both the previous and the current call systems.Although our study results need to be viewed as anecdotaldata, given the small sample size, covering only one trainingprogram, we hope that our study will serve as a stimulus forsimilar studies in other training programs and other special-ties, which may lead to more generalizable results.

Suprit Parida, M.D.

Ramaswamy Viswanathan, M.D.

Lenore Engel, M.D.

Michael F. Myers, M.D.

Hamed Rezaishiraz, M.D.

Ellen Berkowitz, M.D.

From SUNY Downstate Medical Center, and KingsCounty Hospital Center, Brooklyn, NY. Send correspon-dence to Dr. Parida (supritparida@gmail.com).

Note: A copy of the study questionnaire is available uponrequest.

References

1. Landrigan CP, Rothschild JM, Cronin JW, et al: Effect of re-ducing interns’ work-hours on serious medical errors in in-tensive care units. N Engl J Med 2004; 351:1838–1848

2. Philibert I: Sleep-loss and performance in residents and non-physicians: a meta-analytic examination. Sleep 2005; 28:1392–1402

3. Levine AC, Adusumilli J, Landrigan CP: Effects of reducing oreliminating resident work shifts over 16 hours: a systematicreview. Sleep 2010; 33:1043–1053

4. http://www.iom.edu/Reports/2008/Resident-Duty-Hours-Enhancing-Sleep-Supervision-and-Safety.aspx; accessed on 10/02/2011

5. http://www.acgme.org/acwebsite/home/Common_Program_Requirements_07012011.pdf; accessed on 10/02/2011

6. Lockley SW, Cronin JW, Evans EE, et al: HarvardWorkHours,Health and Safety Group. N Engl J Med 2004; 351:1829–1837

7. Rosenbaum L, Lamas D: Residents’ duty hours: toward anempirical narrative. N Engl J Med 2012; 367:2044–2049

8. Drolet BC, Khokhar MT, Fischer SA: The 2011 duty-hourrequirements: a survey of residency program directors. N EnglJ Med 2013; 368:694–697

A Perspective: From the PolicyWorld to the Clinical World

To the Editor: As I read the article from the January 4th,2012, Journal of the American Medical Association, “ADoctor Goes to Washington . . . And Safely Returns” (1), Icouldn’t help but compare my experiences to those de-scribed in the article. Although the author of that piecehad spent over 30 years in medicine, I am fairly new inmy career, but intent upon mixing clinical medicine withpolicy and public service. Last year, I was a health policyfellow at the State Department, where I served as an advisorto the Office of International Health and Biodefense. Thisyear, I am a clinical fellow in consultation–liaison psychia-try at Brigham andWomen’s Hospital in Boston. The policyand clinical worlds are remarkably different, and yet the onething that binds them inextricably is the art of negotiationand being able to compromise with various members ofa team or a system, whether in making policies or in caringfor patients.

I chose to do a health-policy fellowship to attempt to un-derstand how an individual clinician can shape governmentpolicy. While in the fellowship, I had the privilege of wit-nessing policymaking in action while I tried to navigatethe exceedingly complex bureaucracy of our federal govern-ment. I chose the State Department because of its broad in-ternational reach, and I thought this would be the best settingin which to understand policymaking on a macro, inter-national level. While I recently graduated from Yale’s psy-chiatry residency, I realized that the issues I dealt with ona day-to-day basis in DC sometimes had little to do withmental health specifically. Instead, I was often tasked withhelping to develop policies and procedures related to therole of the federal government in the regulation of healthcaredelivery systems and medical research, with implicationsboth within the United States and internationally.

Specifically, during my policy fellowship, I was tasked tohelp reconcile the scientific research community’s pursuit ofresearch that, while therapeutic in intent, may be used ne-fariously, with the government’s oversight of such research

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to guard against possible misuse. This was in the context ofwhether to allow two manuscripts revealing how H5N1, thedeadly bird-flu virus, could be made more lethal while si-multaneously identifying mutations that could be used tocreate vaccines. Although the manuscripts were ultimatelypublished, the process by which that decision was made wasa deliberate one, resulting in taking a painstaking look athow research is conducted. The process involved discussionwith scientists, policymakers, and bureaucrats to address allpossible concerns. Ultimately, new policies were createdthat will clarify the type of research being conducted andhow to communicate findings responsibly.My State Department experienceswere rewarding, allow-

ing me to experience a non-clinical side of medicine, andI would encourage other medical students, residents, andjunior physicians to avail themselves of such opportunitiesearly in their respective careers. I would also suggest toothers in academia or industry that they pursue unique op-portunities to diversify their skill-set, which may broadentheir understanding of complex and dynamic systemsissues. Upon completion of such experiences, one may bein a position to create efficiencies and identify redundancieswithin a system, while bringing to the table innovative ideasfor improvement.Before my departure for DC, I received confused looks

and quizzical responses such as, “What does that have todo with medicine?”My answer is that I believed that expo-sure to the inner workings of our government would indeedadd to my clinical repertoire and offer a unique perspectiveto those making medical and science policy decisions, ulti-mately affecting patients’ lives. What motivated me to seekout these fellowship experiences is my love for and com-mitment to clinical medicine, along with my deep desire tomerge the clinical world with the policy world to have thebroadest impact possible.During both of my fellowship experiences, I have contin-

ued working part-time in a group practice in Danbury, CT.This is less than 10 miles from Newtown, CT, the site of theSandy Hook school massacre. I am caring for patients ina community directly affected by the Newtown tragedy.As an individual in clinical practice with some backgroundin policy, I am now in a better position to understand howdecisions made by lawmakers and bureaucrats can affect in-dividual patients. This has inspired me to take action. I havewritten to the American Psychiatric Association (APA) andbeen in contact with representatives from the APA about thecritical importance of separating mental illness from violentcrime, while also expanding services to those who are trou-bled or ostracized, through early intervention. I have proposed

doing this by extending outreach. This can be accomplishedby having psychiatrists visit with at-risk students in schoolsor other community places to offer resources, lead group dis-cussions, and educate and inform the public at-large aboutthe importance of paying close attention to mental health.There remains shame around mental illness, and seekinghelp is still fraught with stigma; however, perhaps in no othertime in history are we as a society better positioned to shapenational policy affecting individual lives.As a clinical fellow in consultation–liaison psychiatry, I

find myself at the center of coordinating patients’ care andlistening to the multiple stakeholders involved, using theskills I learned in Washington, DC and throughout mytraining, to effect positive change in patients’ lives as theynavigate the bureaucracy of our healthcare system. As apsychiatrist, I have learned how to listen intently, try toresolve conflict, observe group dynamics, “read betweenthe lines,” and offer empathy in tough situations. As a pol-icymaker, I learned the art of negotiating and thinkingabout the broad implications of individual actions. Theseskills are important in the care of patients sometimes toosick to speak for themselves, too incapacitated to under-stand the system, or too overwhelmed by illness.My time with the government gave me an opportunity to

collaborate with other professionals from a huge number ofdiverse backgrounds. These interactions have been eye-opening, and they allowed me to learn how other agenciesare working together for the promotion of our better health.In the rapidly-changing landscape of our healthcare deliverysystem, it will be of utmost importance to provide compre-hensive clinical care in a system of flux, as an aging popu-lation draws upon integrated medical services. Providinggood clinical care can only be accomplished by communi-cating with the numerous parties involved in the care ofan individual, whether they are physicians, nurses, socialworkers, therapists, case managers, or others.As a rising consulting psychiatrist, I am interested in the

mental health of people with comorbid medical problems. Ihope to help expand existing policies to ensure that mentalhealth is on equal footing with physical health, and identifypatients early-on in a hospitalization who may need ourservices the most, so that we can provide meaningful in-tervention in a timely fashion. This early intervention canbe both through clinical interaction as well as policy devel-opment. As care for mental health becomes less stigmatized,perhaps this will lead to more automatic integration of men-tal health into physical health, so that patients are askedabout depression, anxiety, or even psychotic symptoms, atevery well health visit. This could identify more people at

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risk. Early intervention for those most at need would un-doubtedly save lives and could change policies at clinicalcare centers.

I now have a greater understanding of the nuances of pol-icymaking and the tremendous complexities of negotiation.The skills I have developed through my educational experi-ences may be helpful in any setting, whether in clinical prac-tice, hospital management, academia, or industry. AlthoughI do not know what turns my career will take, I certainlyhope to inspire others to pursue rich and diverse experi-ences such as those in government or the private sectoras they find their respective niche. I also hope that I canbe a voice in the ongoing crusade to provide the bestpossible care to patients against a backdrop of increased

clinical complexity and evolving policymaking. I am in-spired to take action, whether by local advocacy or ed-ucational campaigns or simply by writing to relevantlawmakers. It is perhaps the small, incremental steps thatwill lead to the greatest change.

Jessica Chaudhary, M.D.

From Brigham & Women’s Hospital, Boston, MA. Corre-spondence: jessicajchaudhary@gmail.com

The author has no conflicts of interest to disclose.

Reference

1. http://jama.jamanetwork.com/article.aspx?articleid51103998

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