Medical Education Feature - March 2009
Tex Med . 2009;105(3):47-51.
By Ken Ortolon
Total exhaustion from long shifts in the hospital caring for patients around the clock once was a rite of passage for young physicians in residency training.
That changed significantly in 2003 when the Accreditation Council for Graduate Medical Education (ACGME) instituted new limits on resident work hours. Since then, medical schools, residency programs, and teaching hospitals across Texas have spent millions of dollars juggling their training schedules, asking faculty to provide more care, and hiring more physicians and midlevel professionals to pick up the work once performed by residents. They've also had to invest in new technologies to augment training on real patients and to improve the information flow between physicians when residents have to "hand off" their patients to other doctors.
While medical educators and residents alike say the new rules have reduced physician trainees' fatigue, doubts remain whether the work hour limits have achieved their primary goal - reducing medical errors by exhausted residents and improving patient safety. In fact, some residency program directors say the increasing number of patient handoffs necessitated by the work hour limits has had a detrimental impact on patient care.
"We certainly recognize the importance of putting some kind of limitations on resident work hours to avoid fatigue and patient errors and for patient safety," said Philip Orlander, MD, vice chair for education and professor of medicine at The University of Texas Health Science Center at Houston. "But, on the other hand, it does have certain detractions in terms of continuity of care and education, depending on the individual's specialty."
While residency program directors have adjusted to rules imposed five years ago, they now face recommendations for more stringent controls on resident work hours. Thus far, the reaction to the new recommendations from residency program directors and their residents appears to be universally negative. (See "IOM Work Hour Proposals Could Lengthen Resident Training.")
Setting the Limits
The 2003 ACGME work hour limits cap maximum resident work hours at 80 hours per week and set a maximum shift length of 30 hours. Those 30 hours include 24 hours for admitting patients and six hours for transitional and educational activities.
ACGME also set a maximum in-hospital, on-call frequency of every third night and a minimum of 10 hours off between shifts. The rules also require residents to have one day a week free of any residency-related duties.
Residency program directors say those limits have presented serious challenges, both in terms of ensuring that residents get the breadth of experience they need to become competent physicians and in providing patient care in teaching hospitals.
"One of the things we're constantly struggling with is to try and make sure the residents get broad and comprehensive exposure to all of the illnesses and conditions they will be treating on their own without supervision and, at the same time, trying to make sure we're not overworking them," Dr. Orlander said.
Carol Croft, MD, professor of internal medicine and program director for the Internal Medicine Residency Training Program at The University of Texas Southwestern Medical Center in Dallas, says the rules forced her program to make considerable changes in its teaching rounds schedule.
"It's been a real transition for us," Dr. Croft said. "That sacred time of the two hours of attending rounds where everybody was together now can feel a little more chaotic."
John Jay Shannon, MD, executive vice president and chief medical officer at Parkland Health and Hospital System in Dallas, says it is almost impossible to schedule rounds for the entire residency program team - including medical students, residents, and attending faculty.
"If I look at 22 weekdays in a month as potential teaching days, and then I start to overlay my clinic schedules and attending [physician] schedules and the various on and off and post-call times for the residents, I'm lucky if I've got two days out of the 22 when the entire team is there," he said.
The result, he added, is "a substantial change in the experience of the house officer of the patient's illness … because they are missing many more hours of that illness, when previously they would have been called to the bedside much more frequently."
Dr. Orlander says reduced experience caring for real patients forced UT-Houston to adjust its curriculum to make sure topics are covered didactically or through computer simulations. Two years ago, UT-Houston opened a clinical skills lab with an array of mannequins and other technology that can reproduce a wide variety of patient conditions. Residents can even perform procedures, such as intubations or spinal taps, on those mannequins.
"Again, it's not a perfect substitute for the patient, but at least it gives us some pre-patient education so they've done a good number of these procedures on plastic before they have to do it on a patient," Dr. Orlander said.
But Dr. Croft says the best way to learn medicine is at the bedside, and she's concerned residents are not getting the full range of experience they need.
"What you can't learn from textbooks or the now-much-more-easily-obtained information from an Internet Web search is what happens when you make the clinical decision. What happens to your patient and how do you assess whether it was the right decision or not? If the care is disjointed, that part of the learning process is interrupted, and I'm not sure it can be supplanted by the fact that the educational experience is a more restful one."
Picking Up the Slack
The resident work hour limits also forced residency programs and teaching hospitals to spend a lot of money finding other physicians and health care professionals to provide the care that residents once did. Dr. Shannon says Parkland instituted an extensive hospitalist program that uses nonteaching physicians to treat patients. Parkland also hired a large number of physician assistants and advanced practice nurses to pick up some of the slack.
Lois Bready, MD, associate dean for graduate medical education and designated institutional official at The University of Texas Health Science Center at San Antonio, says residency programs and affiliated teaching hospitals there also hired several hospitalists and midlevel practitioners to cover their patient load. That, she says, has been expensive because salaries for those midlevel practitioners can be as much as $125,000, plus benefits. According to the Association of American Medical Colleges, the average first-year resident stipend was only $46,245 in 2008.
There isn't any state or federal money to cover those costs, she says.
Other increased costs include purchasing information technology, such as electronic medical records, to improve information flow between the various physicians who may care for a patient during the course of his or her hospital stay.
Dr. Shannon says the work hour limits caused a definite shift in who is providing care in the hospital. In the past, if you wanted to know what was going on with a particular service, you'd talk to the senior resident, he says. "Nowadays, the person with the most knowledge of what's going on with the service is the attending physician. That definitely would not have been the case in the past." There are no work hour restrictions on the attending faculty, he adds.
A Mixed Bag
Residents themselves appear to have mixed feelings about the work hour limits. Mark Warner, MD, chief medical resident and clinical instructor in the Department of Internal Medicine for the UT Medical School at Houston, says the residents enjoy the cap on the number of hours they are in the hospital. "I think they enjoy having sort of a goal - once I get to this certain time I can go home and rest for a little while and come back the next day. I think that's definitely a plus."
Eddie J. Turner Jr., MD, a third-year family medicine resident in the Baylor College of Medicine Northwest Residency Program and chair of Texas Medical Association's Resident and Fellow Section, believes the current work hour rules have been "very positive, especially from a patient safety standpoint. And I think that should be our main goal - patient safety and, secondly, our resident well-being."
But both residents and program directors say there is considerable frustration among dedicated residents who don't want to leave a patient in the middle of a critical care episode just because their shift is over. Residents also recognize the value of the hands-on experience they may be missing.
"The only glaring thing that we hear from the residents consistently is if they're approaching that 30th hour and they have a patient who's not doing well, that requires some personal attention at the bedside, the residents would like to stay and take care of their patient," Dr. Warner said. "And sometimes that's just not possible. When they get over the hour limit, they have to hand that responsibility off to someone else."
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at Ken Ortolon.
IOM Work Hour Proposals Could Lengthen Resident Training
New proposals by the Institutes of Medicine (IOM) to place additional limits on resident work hours could dramatically impact residency training and patient care in teaching hospitals. And, they could force some specialties to lengthen their resident training periods, say medical educators.
In December, the IOM recommended several changes to the resident duty hour restrictions imposed by the Accreditation Council for Graduate Medical Education (ACGME) in 2003. While the recommendations maintain the current work hour limit of 80 hours per week, they would limit moonlighting by residents and require additional days off. The proposals maintain a resident's maximum shift length at 30 hours, but require a five-hour sleep break after the first 16 hours of that shift.
The IOM recommendations also would increase minimum time off between shifts for night and extended duty periods, increase the mandatory number of days off per month from four to five, and count moonlighting both within the teaching hospital and in external facilities against the 80-hour work limit.
The American Medical Association congratulated the IOM "for its proposal to enhance the learning environment for resident physicians and to reduce medical errors" resulting from resident fatigue.
Residency program directors in Texas say the five-hour sleep break would automatically cut resident productivity by one-sixth, requiring them to hire more physicians and midlevel practitioners to pick up the slack.
And, some specialties would have major compliance problems, they say.
Carol Croft, MD, professor of internal medicine and program director for the Internal Medicine Residency Training Program at The University of Texas Southwestern Medical Center in Dallas, says certain surgical subspecialties, obstetrics and gynecology, and other specialty programs might need exceptions to the proposed 16-hour rule.
For obstetrics and gynecology, for example, one of the learning experiences is to evaluate a woman in labor and see her through delivery.
"If she's in labor for 24 hours, you can't take the resident away from the patient whom he or she may have followed through the entire pregnancy, and say 'Sorry, it's nap time' when the baby's arriving," Dr. Croft said.
Eddie J. Turner Jr., MD, a third-year family medicine resident in the Baylor College of Medicine Northwest Residency Program and chair of Texas Medical Association's Resident and Fellow Section, says he doesn't see how the proposed sleep requirements could be enforced.
"When we do call, we're usually the only resident on call," Dr. Turner said. "If we were to have to take five hours for sleep, there is nobody to cover for us. So it would take a major overhaul in the way we do our curriculum and our training."
Lois Bready, MD, associate dean for graduate medical education and designated institutional official at the UT Health Science Center at San Antonio, says many residents are worried about the consequent loss of experience and "the anticipated prolongation of their residency training requirement" that the new proposals might entail.
"Some residency programs rely extensively on counting the number of key index experiences, whether they are surgical cases or experiences of a given type in some other specialty or months of rotation in a specific clinical assignment," Dr. Bready said. "If you're talking about specialties that count clinical experiences and there's less time to acquire those clinical experiences, it would almost be certain that they would have to be extended."
Dr. Croft also says she worries that the proposed moonlighting restrictions would force moonlighting "underground."
"What we currently have for internal medicine because of the hospitalist programs is availability of shifts where residents can moonlight within the teaching institution," Dr. Croft said. "That means that if licensed trainees who are eligible to moonlight do moonlight, they're going to be in their own teaching hospitals. In some respect, they have access to the faculty, to the more senior trainees, fellows, or residents who are older than they are, while they're having a moonlighting experience." She believes that would be a learning experience that moonlighting at an external facility might not provide.
She says ACGME is taking work hour violations very seriously but as yet has not adopted the IOM recommendations. Ongoing discussion on how best to implement them is expected in the coming year.
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