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Have Resident Work Hour Restrictions Compromised Training - a Pediatrician’s Perspective

Author: Merlin C. Lowe, MD, FAAP | Submitted: August 26, 2009. Updated: September 21, 2009.

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Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.

 

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ABSTRACT:

With many recent changes in residency requirements, one must wonder how effective our residency training system is. Are residents still learning the required information to perform well? Is the new system just as good as the old but in a "kinder" way? Ultimately, time will tell; however, for successful residency programs ongoing evaluation and resulting changes will be needed to ensure that the newly imposed limitations don't end up sacrificing quality at the expense of meeting these new requirements.

Having graduated from medical school in 2003, I was among the first group of interns to begin under the new residency work hour reform mandated by the Accreditation Council of Graduate Medical Education (ACGME) in which residents had many time limitations imposed upon them.1 These new rules include an 80 hour work week, with no longer than 30 hours in one continuous shift. With the 30 hour limitation came the mandate that residents could only admit patients within the first 24 hours of their shift and after the 24 hours had passed they were no longer to be doing active patient care. The remaining six hours were allowed for finishing paperwork and completing necessary tasks. The 30 hour limitation brought with it a whole new set of difficulties to overcome. No longer could a resident attend their continuity clinic post call since this would put them in violation of their 30 hour restriction. This effectively eliminated the ability to have a set call schedule since there would need to be periodic rearranging to allow for continuity clinics. Night shift rotations had to be adjusted because there needed to be a minimum of ten hours between shifts and some residents found themselves coming back the next night only eight or nine hours after they left that morning.

Having been a medical student on clinical rotations before the 30 hour week was imposed, I saw and experienced some of the extended shifts of 36 plus hours with limited time in between shifts. I experienced the work hours of 110+ hours per week. This system, in itself, proved to have its own dangers. Many studies have evaluated the safety issues with these extended hours, not just for the residents themselves but also for patients.2,3,4 The burden was placed on the resident to overcome these issues and learn to effectively and safely manage patients with such a heavy schedule. Most succeeded but there certainly were countless reports of residents committing errors due to fatigue or having accidents while driving home exhausted.2,3,4 In response to these brutal hours, the resident often had a sense of pride in putting him/herself through such difficulties and coming out on top. Ultimately, residents would finish residency having learned to navigate these difficult hours, but at what cost? How many near misses did one encounter during these extended hours of training?

The new limitations worked to shift the burden of safety from the resident to the program and improve the quality of life of the resident. Several studies have been done that show an improvement in patient care outcomes thus far, indicating that the work hour restrictions are having their desired effect. One such study reviewed several factors, including length of stay, intensive care unit use, need for pharmacy intervention to prevent medication errors and in-hospital deaths.5 In this study, 3 of the 7 areas showed improvement (need for ICU, discharge home or to rehab vs. another place, and pharmacy intervention to prevent errors) and no adverse consequences were noted.

As initial studies such as this internal medicine study indicate, I believe overall these restrictions have succeeded. I am concerned, however, that the amount of training the residents receive has been severely compromised. In reducing the work week from 120 to 80 hours, the amount of patient interaction time has effectively been reduced by 1/3rd. A study assessing the number of surgeries performed by 4th and 5th year residents demonstrated that while 5th year surgical residents did not see a significant drop in the number of surgical cases they performed, 4th year residents experienced a 45% decrease in the number of their cases.6 It is my opinion that only so much can be learned from a text book and the rest of medicine needs to be learned by direct patient experience. These resulting decreases in patient care experiences may ultimately have a negative impact on future patient care abilities.

As a pediatric hospitalist, I see residents in their inpatient rotations now having to leave the wards early to go to clinics or leave post call. The amount of afternoons spent on the unit have been reduced to a minimum with these changes. So, is this a bad thing? In the last several years since these changes have been in place (starting in July of 2003), it is my impression that successful passing of the pediatric board certification exam has not decreased, indicating that there has not been a knowledge gap created. This has been confirmed in surgical residencies where training exam scores did not decrease following institution of work hour limitations.7 I do question, though, if we are setting our residents up for a trial by fire when they become attendings and no longer have these rules to protect their time. Will they be able to function seeing 40 patients a day in clinic or working 48+ hours in an extended shift over the weekend? I think we've not yet seen the answer to this. In addition, residents are no longer seeing the full progression of diseases since they are signing out so much more often. This is particularly difficult in pediatrics since patients often do not have long stays in the hospital. Seeing 100 "typical" bronchiolitis patients from beginning to end allows one to identify the patient with a complication who is no longer typical.

My greater concern is that I have sensed a shift in resident "attitude" such that patient care is no longer first priority. I agree that there needs to be a balance between patient care and resident education; however, I am concerned that I am seeing a greater willingness of residents to simply say, "this is not my job" or "I'll be in violation of the requirements if I do this." I am not advocating for breaking the rules and having residents overextend themselves but I do think there needs to be a sense of personal dedication and responsibility to the patient. On an individual level, I still think most residents are willing to do what is needed but on a corporate level there seems to be a dangerous shift going on. The advantage of the old system was that each resident was responsible for caring for the patient and seeing that everything needed was accomplished. Now, I am seeing a much greater willingness to simply let someone else deal with an issue that has arisen. So... Would extending residency by another year or two help this? It may help in knowledge base but is unlikely to help with these "character" issues. And, are these issues necessarily bad things, especially in light of the hospitalist movement in which attendings are also transferring care of their patients to colleagues more frequently?

Time will give the ultimate answer. Interestingly, before we really have the answers to these issues, there are already rumors of further restricting work hours. One thing is for certain though, regardless of whether these changes are good or bad, the stories of those who went before these restrictions will continue to ring "Back in my day..."

Conflict of interest statement

No financial conflicts or disclosures to report.

CITE THIS ARTICLE:
Merlin C. Lowe, MD, FAAP. Have Resident Work Hour Restrictions Compromised Training - a Pediatrician’s Perspective. Doctors Lounge Website. Available at: http://www.doctorslounge.com/index.php/articles/page/295. Accessed July 29 2014.

References



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September 26, 2009 08:35 PM

I agree, Dr. Foaud.  At my institution, the restriction in work hours was not met by an increase in resident numbers.  The attending physicians were required to make up deficit.  As such, one of the other trends I am concerned about is that more and more of the responsibilities that residents once carried are being shifted to attendings.  This deals with the deficit in physician presence but, again, pulls more training opportunities from the residents.  Time will tell what ultimately happens but it does behoove us to be cautious as we move forward in this area.

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September 26, 2009 05:29 PM

Thank you Dr. Chan for this comprehensive article. While there are many articles about the effects of resident work hour restrictions on patient care and overall performance, this article touches on a vital aspect of medical care: i.e., training.

If education and training are indeed affected by the new rules then the effects on patient care and overall performance may not be obvious for some time. The presence of well trained senior staff may act as a safety net, mitigating disasters in patient care before they occur. If subsequently, they are replaced by inadequately trained physicians the whole system could possibly collapse.

Increased work hour restrictions leads to increased fragmentation of patient care, as the patient is less likely to be followed up by the same physician. Ironically, such a system requires better trained staff that would be able to work more efficiently under these challenging circumstances. That’s why I would add my voice to yours regarding being cautious about implementing more restrictions before the effects of current restrictions are adequately assessed.

Were the work hour restrictions accompanied by a complementary increase in the number of residencies and residents per hospital? Otherwise, work hour restrictions would mean that patients also experience resident-care restrictions.

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