The 80-hour experience: What happens when residents have to leave

The jury is still out on whether limits to residents' work hours hurt or help educational training, but the rules are here to stay.

By Myrle Croasdale — Posted July 25, 2005

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When Jamie Chang, MD, learned that resident work hours were being capped, he was concerned that his education would suffer.

Two years later and now chief resident of internal medicine at the University of North Carolina Hospitals program in Chapel Hill, he considers his training good overall, but he clearly has less time for lectures and less continuity with patients.

"I worry about that a lot -- if resident education is as good as before," Dr. Chang said. "From the standpoint of working on the wards, patient care, that hasn't decreased. Our hospitals have added ancillary personal to help out with that. I don't have objective data, but my gestalt is that attendance at noon conferences is down. I know when the hours were introduced, I personally was unable to make it to as many conferences as before. ... On the whole, though, I think people are coming out quite well."

Two years into resident work-hour reforms, there is little consensus among those in medical education about how the work-hour restrictions are impacting the quality of education. Some experts believe that residents aren't getting the same breadth and depth of experience as those who came before them. Others believe that becoming a competent physician requires focused hours in the hospital, not endless hours in the hospital.

Deborah DeMarco, MD, associate dean for graduate medical education at the University of Massachusetts Medical School, said it's too soon to tell which opinion will prevail.

"I think the bottom line is that we don't have the data yet, so I can't answer in an evidence-based way. There's only anecdotal evidence, some of which is positive and some negative," Dr. DeMarco said.

A survey of medical residents and students at her school is telltale. Some said the hours are great, giving them more time to spend reading and participating in educational activities. Others felt it interrupted continuity of care to a degree that hurt patients.

"Frankly, I think a lot feel guilty," she said. "They're signing out before finishing and feel they're missing out on educational opportunities."

The Accreditation Council for Graduate Medical Education, which instituted the landmark hour limits in July 2003, established a committee on learning innovations to identify unintended consequences and to find successful programs that can be used as models for those that are struggling. Resident review committees, which operate under the ACGME, also are considering what guidelines might be fine-tuned.

Most programs are complying with the rules, under which residents may work 80 hours a week, averaged over four weeks, and no more than 30 hours during in-hospital call. The ACGME has granted exceptions to 75 programs, where residents work 88 hours a week. During the 2003-04 academic year, the ACGME gave 135 citations for duty-hour violations out of 5,450 total citations.

William J. Howard, MD, chair of the ACGME committee on learning innovations, said surgical programs have had the greatest difficulty with the hours restrictions because the number of cases performed is considered critical to training.

"We have a successful but very old paradigm of medical education," Dr. Howard said. "It's an on-the-job, case-based method, with residents participating in a graded increase in patient care. No one can argue the success of it, but many things have changed, while the system hasn't. ... Some are trying to shoehorn this old paradigm into the new requirements without taking into account how to make it better."

Surgical residents say leaving when they've hit the 30-hour limit forces them to miss unusual cases, but Dr. Howard is unapologetic about duty hours. "If you look at the research, there's a well-documented decline in judgment, motor skills and patient safety with continuous time on task. It's awfully hard to argue that making changes to ensure physicians are rested up and at their peak, not their nadir, is wrong."

A 2004 Harvard Work Hours, Health and Safety study showed that interns made 36% more serious medical errors when working 80 hours a week with 24 hours on call compared with 63 hours a week and 16 hours on call. Another said interns were twice as likely to have a car crash after working 24 hours or more.

Mixed results

Research on the impact of work-hour reforms on surgical residencies shows a range of results.

A national survey of neurosurgery programs by Mayo Clinic researchers found that 93% of responding program directors and residents felt that the reforms hurt continuity of patient care, and 41% of program directors felt chief residents were operating on fewer complex cases. A study by the Dept. of Surgery at the University of California, Irvine, found that surgical residents were not losing time in the operating room or clinic but were cutting back in other education areas, such as lectures.

Steven Daugherty, PhD, assistant professor in psychology and preventive medicine at Rush Medical College in Chicago, and DeWitt Baldwin Jr., MD, a scholar at ACGME, are looking at the ways residents learn during their training.

"A lot of education happens in sideways interactions," Dr. Daugherty said. "Residents learn from each other, but with residents now on shifts, there's less overlap.

"The positive side is this helps each resident learn more responsibility and self-management skills," he said. "The negative side is clearly they have less time to have conversations with other residents."

Residents do have more time to read journal articles, and those who are good at self-directed learning might be fine, Dr. Daugherty said.

Tom Varghese Jr., MD, chief general surgery resident at Northwestern Memorial Hospital in Chicago, said he sees this play out in his program, which has been cited by the ACGME as a model in innovation.

During what's called the apprenticeship rotation, a single resident is paired with one or two faculty members, giving the resident intense interaction with the attendings and the opportunity to perform many procedures. The trade-off, he said, is that junior and senior residents miss out on learning from their chief resident, who is closer to the nuts and bolts of resident life and can have a lot to offer.

Alex Valadka, MD, a neurosurgeon at Baylor College of Medicine in Houston, said the new work-hour rules created a new set of pluses and minuses on several levels. Residents get more time with attendings, but attendings are seeing workloads increase because of the additional teaching time. Often this requires them to cut back on research, which is vital to their being promoted.

While everyone isn't happy with the duty-hour rules, Dr. Valadka said the rules haven't lowered the standard for U.S. medical training. "It just makes it more of a challenge to come up with ways to still provide a good, quality education," he said.

Overall, he is optimistic about the impact of 80-hour weeks on this generation of physicians. "People my age brag that we were in the hospital all night, but the key question is does that make you any better prepared?" he asked. "What if I had had time to go home and read?"

Jeremy Denning, MD, chief neurosurgery resident at Baylor, isn't as confident that residents are getting the same quality of training as their predecessors. As chief, he doesn't miss out on surgical procedures because of the work hour limits, but the senior residents do.

"The morning following call, when you're getting into the meat of the operation, the bell rings and it's time for them to scrub out. ... As far as overall education, they're not getting what I got," Dr. Denning said.

John J. Coyle, MD, associate professor of gastrointestinal and endocrine surgery at Northwestern University Feinberg School of Medicine, has headed up many of the training changes at Chicago's Northwestern Memorial Hospital. He's unfazed by such complaints.

"The 80-hour workweek has enhanced procedural training," he said. "The number of things I learned on nights and weekends after my first year, I can count on one hand. What I'm telling you is to step back and re-evaluate everything from scratch."

He said senior residents were kept in the hospital overnight as a proxy for the nursing service and faculty, but he questions how much learning really took place. Dr. Coyle said Northwestern's surgical residents' caseloads held steady during the first year of restricted hours. During the second year, the number of procedures has risen 10%, and residents have about three hours of protected time for formal educational activities.

Even model programs such as Northwestern's continue to wrestle with the hour constraints -- Dr. Coyle knows his faculty "cheat" and steal residents, inviting those apprenticed to other faculty to scrub in on an interesting case and duck out on less sexy work. Even the most avid proponents are wary of the pitfalls these changes could create, such as residents no longer being able to treat patients from admission to discharge. Yet at the end of year two of 80-hour workweeks, many physicians are guardedly optimistic.

Lee Berkowitz, MD, president of the Assn. of Program Directors in Internal Medicine and director of internal medicine residents at University of North Carolina, said it's a matter of creating a different learning paradigm.

"In some ways it's richer," Dr. Berkowitz said. "You see more patients and interact with more people, staff. The major difference is clinical learning. ... We have a long tradition of 'That's my patient and I follow that patient through.' In some ways that's very laudable, but residents need to learn closure."

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Too tired to learn?

Since July 2003, medical residents have been limited to an average of 80 hours per week and in-hospital call of no more than 30 hours. But even with the new hour constraints, residents are still sleep-deprived. A survey of 1,126 medical students and 1,011 residents by the AMA's Member Connect program found:

  • 69% of residents and 66% of medical students believe sleep deprivation or fatigue could have a negative effect on their learning.

  • 50% of residents and 45% of medical students believe that this also has had a negative effect on the quality of patient care they deliver.

  • 50% of residents and 75% of medical students felt uncomfortable with reporting work-hour violations. Most residents knew how to report excessive hours, but only a quarter of medical students did so.

  • 29% of residents and 26% of medical students felt that sleep deprivation or fatigue put them in physical danger. The majority reported that they had been in a car crash or near miss because of fatigue.

  • 11% of residents worked more than 80 hours per week, while 12% of medical students did so.

Source: AMA Member Connect

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Breaking the rules

The Accreditation Council for Graduate Medical Education reviewed 2,027 of 8,192 resident programs in 2003-04 and surveyed 29,000 of 99,964 residents. It found:

  • 5,450 citations were issued; 135 for duty-hour violations.
  • 53 whistle-blower complaints were made; 42 were deemed worthy of follow up.
  • 15% of residents in 81 programs reported working more than 80 hours a week.
  • 15% of residents in 282 programs reported working more than 30 hours during in-hospital call.
  • 50% of residents in four programs reported working beyond the weekly limit.
  • At least half the residents in 12 programs worked beyond the 30-hour limit for call.

Source: ACGME, American Medical Association

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Making handoffs efficient and effective

One consequence of the 80-hour workweek has been an increase in patient handoffs, which critics say increases the chance for errors.

Erik Van Eaton, MD, a surgical research fellow at the University of Washington, and his colleagues designed a system they hope will mitigate such concerns. UWCores is a computerized resident sign-out system intended to make it easier for residents to keep track of their patients. Results of their work are in the July 2004 Surgery.

Dr. Van Eaton said residents increasingly were writing their own patient lists, adding in vital signs, recopying information into patient charts and copying the lists again for the next resident. Using Cores, they record the data once.

Cores also adapts the standard electronic medical records system, which requires residents to sign in as the patient's physician.

Dr. Eaton said the standard system doesn't make sense for residents.

"Residents don't stay in one place," he said. "Tomorrow I go to the VA and a new resident takes my place. The problem is that all the information about those patients keeps coming to me, instead of to the new resident."

With Cores, new patients are added to responsibilities of a particular title or role, not to an individual resident. The resident on duty signs in as the leader of internal medicine team A, for example, and Cores retrieves his or her list of patients.

Cores has been popular. In its first six months, the number of residents using it jumped from 45 to 800, Dr. Van Eaton said.

The software is being licensed and is available for free. For more information, e-mail the University of Washington clinical informatics research group (link).

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