Beat the clock: The new challenges to residents

It's dark outside and the lights are dimmed on the pediatric neurology ward at the University of Chicago's Bernard A. Mitchell Hospital. Christian Sikorski, MD, on morning rounds, checks on an infant with a shunt, a child with a severed spinal cord, another with electrodes protruding from his skull and one with a brain-damaging sinus infection.

Nurse practitioner Judy Holleman checks on other patients, then briefs Dr. Sikorski. Before July 1, 2003, Dr. Sikorski would have been rounding alone for the neurosurgery team.

Holleman's presence is one of several changes made in the neurology program at the University of Chicago to comply with new 80-hour workweek rules, which are reshaping medical training in the United States. For residency programs across the country, the challenge is to ensure that residents treat enough patients and perform enough procedures to become proficient and maintain patient safety during the increased number of patient handoffs that are the inevitable result of a shorter resident work day. Halfway through the first year of 80-hour weeks, it's still unclear whether the duty-hour limits have hurt residency training or whether patient safety has been affected. What is clear is that the programs that have made a successful transition have embraced a culture of change and have found ways to free residents from menial tasks.

Dr. Sikorski, a fourth-year resident, said nurse practitioners have cut hassles out of his day. A myriad of minor requests used to pile up while he was in surgery and his demand attention when he left the operating room.

"I used to have to [hurry] back [to intensive care]," he said. "Now the floor pages the nurse practitioners first."

Resident programs are taking the limits seriously, said David Leach, MD, executive director of the Accreditation Council for Graduate Medical Education, which accredits all residencies. But, he said, it is how they approach the task that makes the difference in the kind of education residents receive.

"There are early adopters and innovators who have shown you can improve patient care and [meet duty-hour limits]," he said. "The majority have shown you can do this, but in making do they've not redesigned clinical care as much as reacted to the requirements. In a few of our citations, programs have met the requirements but have weakened patient care and resident education."

The ACGME has reviewed 500 to 600 programs since July 2003 and has issued 79 citations related to duty-hour violations, Dr. Leach said.

Residents aren't completely happy with the new constraints either.

"You have to realize that the larger health care system is broken," Dr. Leach said. "Residents have lived in the cracks of that broken system for a long time, and they've been told that the system can and will kill your patient, and you need to make sure that doesn't happen. Residents have depended on vigilance, knowing that the system can't be trusted. Now we've reduced the availability of the residents, and they're worried. They want to stay [at the hospital] because they can't trust the system."

An ongoing challenge

Anecdotal reports abound of residents looking for ways to get around the work-hours rules and of programs coaching residents to lie about their hours.

But some programs stand out as models of what can be done when faculty and hospital administrators are willing to rethink their way of doing business.

Boston Medical Center has been cited as an institution that has successfully made the transition to the 80-hour workweek, though John Chessare, MD, MPH, senior vice president for medical affairs at BMC, points out that adapting to the work-hour rules is an ongoing challenge for the medical center.

When it came to scheduling shorter hours for residents, the hospital had a head start. The housestaff had been working toward a shorter week through its union, the Committee of Interns and Residents. When the ACGME made the 80-hour cap mandatory, some of BMC's residency programs were already in compliance. Those that weren't had to come up with a plan.

General surgery started sending first-year residents home in the morning after call instead of having them stay to help with nonphysician surgical tasks. Instead, second-year residents now scrub and expand their skills, and a nurse performs the nonphysician tasks.

Surgery attendings now take night shifts for extra pay. The cardiothoracic surgery program added physician assistants, and the orthopedic surgery program hired another resident. Seven phlebotomists are in the process of being hired to draw blood.

Technological changes, which already were in the works, add to the reduction in paperwork. Attending physicians can put in prescription orders from their offices or homes. Post-discharge papers are scanned into the computer, further reducing the amount of paper residents shuffle.

Attending physicians are working more to fill in the coverage gaps, and this has also led to system change. "As soon as the attendings realize they are doing extra work, amazing things happen," Dr. Chessare said.

Residents tend to keep silent about problems to avoid looking like complainers, but faculty feel empowered to speak out and fix things, he said.

At BMC, it used to be that surgical oncology residents rounded in the morning and headed to the operating room after rounds, leaving discharges for later. This created a backup at 5 p.m., which then fell on the attendings. In response, the faculty decided to write patient prescriptions and discharge orders at the bedside during rounds.

"When the residents got out of the OR, there was that much less work to do," Dr. Chessare said. "This hours thing is forcing us to focus more on work redesign."

Jeffrey Upperman, MD, associate professor of surgery at Children's Hospital of Pittsburgh and an associate fellow of the American College of Surgeons, has experienced this himself. Though physician extenders have been hired to help with the workload, on a good week he works 70 to 75 hours. When he is on service, that goes up to 80 to 90 hours.

He and his partners now take call, though not as frequently as the residents. He has encouraged his fellow attendings to not just endure on-call duty but to remedy the system problems they encounter.

For instance, changes were instituted after Dr. Upperman received midnight calls to renew a patient's expiring medication orders and to confirm whether a patient should get a multivitamin.

"This is nonsense," he said. "Certain things can be triaged."

The nurses now write down all the issues that arise during their shifts and categorize them by importance. When the intern arrives at 11 p.m., he or she can take care of the low-priority tasks, then from 11 p.m. to 5 a.m. unless it's an emergency, the list is put into a triage book that the attending physician checks in the morning.

But even with the efficiencies that new systems have created, some worry that shorter resident hours will create a less-experienced generation of physicians.

Ronnie Mimran, MD, a sixth-year neurosurgery resident at the University of Florida, said this would make sense, since fewer hours mean that his caseload has dropped 20%. But he has found that added sleep gives him time to study more and take better advantage of his cases.

"Forty-five of 50 residents would bear ill will to these changes, but I'm one of the five who doesn't," Dr. Mimran said. "When I was a junior resident, I was a mess. I was not fit to take care of patients three out of seven days a week."

Now, he feels prepared to take on the challenges of patient care.

"I think I've become a better doctor, because tomorrow's patients are benefiting from what I can do today," Dr. Mimran said. "I can find out what cases are coming, I can read about them. I can look up similar cases. I can search my log notes -- this is where you screwed up last time. Don't do that again."

Still, many in the medical profession see the rigid hour limits as a hindrance to education and are skeptical that the duty-hour limits will improve patient safety. Thomas Einhorn, MD, chair of the orthopedic surgery department at BMC, has embraced redesigning the system, but he doesn't like it.

"I already know of poor patient care decisions and outcomes resulting from the on-call doctor not giving a good handoff, which is a symptom of the 80-hour rule," he said.

A checkoff sheet has been created for patient handoffs, but there's no guarantee that it's going to solve the problem, he said. "It's one thing to convey information and another to experience caring for a patient and then make a decision."

Meanwhile, at UC

Eleven hours later at the University of Chicago, it's 6 p.m., 12 hours since the residents started their day. The sun has gone down and no one has seen the light of day. One team is still in the operating room working on a complicated aneurysm. Dr. Sikorski is escorting his last patient into a recovery room. He's on call the next day and has his sights set on wrapping things up for today.

His colleagues have mixed feelings about the work hours.

One is convinced that the rules eventually will mean an extension in the length of training programs because studies show that the more procedures performed the better the doctor becomes at them. Another sees common sense in reining in a system that once had him reeling from 130-hour weeks.

For Dr. Sikorski, the chance to get some sleep tonight before he goes on call tomorrow is a blessing. "You'd be crazy to want to work more hours," he said.