A work in progress: Reshaping residency

Cutting residents' hours triggered a string of changes that the ACGME hopes will benefit, not hurt, the medical profession in the long haul.

By Myrle Croasdale — Posted March 13, 2006

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

Physicians agree that curtailing residents' work hours has had a tremendous impact on the medical profession, but whether it's been for good or bad is still up for grabs.

The controversial decision to limit residents to an average of 80 hours a week, 30 hours straight of in-hospital call and call frequency no more than every third night had many concerned that residents' training would suffer because they would miss out on the continuity of caring for a patient from beginning to end. There also was fear that hospitals would be short-staffed and that others in the system would be left to cope with the work overflow.

So far, studies have shown that, to some degree, all of these things have occurred. But there's also evidence that some programs are developing ways to protect residents' hours and learning experiences.

Those who support the new rules say the effort will make physician training better and patients safer in the long run, including David C. Leach, MD. He is executive director of the Accreditation Council for Graduate Medical Education, the institution that put these rules in place July 1, 2003. AMNews reporter Myrle Croasdale recently talked to Dr. Leach about the changes.

AMNews: A number of studies have come out since the work-hour rules were put into place. A recent one found that medical students were spending more time doing administrative tasks and less time learning. Another found that faculty were picking up more of residents' patient care duties at the expense of career-advancing research. Are the duty-hour limits shortchanging those who don't have hour restrictions, such as faculty and medical students?

Dr. Leach: All of these issues are in play with duty hours, but there's not a doubt in my mind that we did the right thing. There's also no doubt that, at first, it made things worse.

In the comments we get from our survey [the ACGME has begun an annual Internet survey], residents have said a number of things. Some mention that they have more balance in their lives, more time to reflect. There are also comments: "I used to be with another resident at night." "Now I have less time with faculty." "I'm doing more work and have no time for noon conferences." Before, residents were too exhausted to be fully available to patients.

I'm proud of the changes we made, but we need to refine them. That's why we have the CILE [formally known as the Committee on Innovation in the Learning Environment, which identifies unintended consequences of the duty-hour changes and to find successful programs to use as models for those that are struggling with training residents in the confines of shorter hours]. The implementation of duty hours calls for a redesign of the larger system. We need a health care delivery system in place that's safe and provides excellent care. This sort of redesign will result in better patient care and happier faculty. But if you just accommodate the 80 hours [without changing other elements], then everybody is miserable.

AMNews: One of the reasons duty hours were imposed was to improve patient safety. Are patients safer now?

Dr. Leach: Increasingly, Americans are recognizing hospitals as dangerous places. There is a major effort among organizations to improve safety, and it's very clear that to have a change in the culture, we must first be upfront about errors and have open disclosure.

Yes, patients are safer in that duty hours addressed one of the human factors that contributes to errors -- fatigue. But it's much broader than that. Currently, the system is designed to make it fairly easy to make an error.

AMNews: When the hours rules first came out, you said you were concerned that medicine as a profession could either improve or get worse. Which way is it going?

Dr. Leach: The signals are that it's getting better. More hospitals are making public their patient care outcomes, like the Dartmouth Atlas of Health Care [Web] site. Putting the good and the bad out there creates a compelling agenda to improve health care. ... There is a growing consciousness of the differences between discretion and discipline. Physicians need discretion to take care of such things as pneumonia, while there are protocols to follow for something like class I anesthesia, which makes that safer.

AMNews: Some residents say that with just 80 hours at the hospital, they don't have time for noon conferences and are missing out on educational opportunities. Are we graduating physicians who are less well trained and less skilled than the generations who trained before the work hours restrictions were put into place?

Dr. Leach: Residents are better trained. Now it's increasingly common to have simulations in which residents rehearse, and it's very safe. They get the skills, and it's not dependent on the patient. They can polish their skills before going to the bedside. ... Noon conferences are going to dry up and blow away. They aren't strong enough to give the new knowledge that's exploding.

AMNews: What does the future hold for evaluating residents and their education?

Dr. Leach: Outcomes are not all measured quantitatively. You can circle something on a Likert scale, and that's helpful, but people always go to the comment section. Our lives consist of a series of stories and in telling the stories you get to a truth. ... The next big change will be learning portfolios. It could be the new accreditation model. I didn't know much about them, but when I googled "learning portfolio," it took barely a second to turn up thousands of references. And I talked to my COO -- his son has one. It has his various freshman homework assignments posted and a journal reflecting on what he's learning. I realized I was the only one who didn't know about them.

I see residents with portfolios as a catalog mapping their experiences to objectives. It will have experiential data and a reflective element, stock assessments and evaluations, case logs, number of patients seen, mentor encounters, videos of simulations. Then the learner could construct it for presentation for hospital credentialing, licensing. ... In the future, to meet ACGME requirements, programs will have information on the six competencies for residents in portfolios. [Which would be creating] a database for doctors for life. It will be information verified and governed by a new body with members from professional organizations.

AMNews: What's ahead for the ACGME?

Dr. Leach: It's a big year for the ACGME. It's our 25th anniversary. We'll have a gala [in Chicago] on Navy Pier in June.

We just completed our strategic plan for the next two to three years.

Our first goal is to look at improvements in the accreditation model. We have been using a minimal-threshold model. Now we want to encourage innovation. We're piloting a two-class system of accreditation where if you meet the minimal threshold, then you don't have to go through the process as often.

Second, to measure outcomes through portfolios. Third, to reduce the crush of forms and removing steps that take time but have little value, and fourth to have conversations with others about how to speed up accreditation.

Medicine is on a journey to authenticity, and that's a wonderful journey, but it gets bogged down in the swamps and at times is self-serving. I'm an optimist, and I think we will emerge as a trusted profession.

Back to top


Analyzing the change

Although the 80-hour limit for residents' work weeks is barely 3 years old, it's been much studied. Here's what researchers are finding:

Interns made 36% more serious medical errors when working 80 hours a week, with 24 hours on call, than they did working 63 hours a week with 16 hours on call. (New England Journal of Medicine, Oct. 28, 2004)


Interns were twice as likely to have a car crash after working 24 hours or more. (New England Journal of Medicine, Jan. 13, 2005)


Among 164 internal medicine residents at three University of California, San Francisco-affiliated hospitals, 69% surveyed shortly after the 80-hour-week restrictions went into effect reported spending the same, or less, time in educational activities such as teaching and conferences; 60% said they had not increased their reading time. (Academic Medicine, January)


Half of residents and 45% of medical students believe sleep deprivation has had a negative effect on the quality of care they deliver, according to an AMA survey of 1,126 medical students and 1,011 residents. Half of the residents and 75% of medical students felt uncomfortable reporting work-hour violations. (AMA Member Connect, 2005


Duty-hour restrictions led surgical faculty at five academic and four nonacademic U.S. residency programs in general surgery to have lower expectations and standards for residents. Faculty also said they had less time to teach, less satisfaction, and more work and stress. (Academic Medicine, January)


One-third of obstetrics and gynecology residency programs (excluding New York state) made modifications that resulted in a decrease in clinical experiences for residents. (American Journal of Obstetrics and Gynecology, January)


Back to top

Bio box

Name: David C. Leach, MD

Title: Executive director of the Accreditation Council for Graduate Medical Education

Medical school: University of Rochester School of Medicine and Dentistry

Age: 62

Family: Wife, Jackie; son, Derrick; daughter, Heather

Hometown: Chicago

Experiences: Staff pediatrician for 28 years in the Henry Ford Health System in Michigan and assistant dean at the University of Michigan for several years before being appointed director of medical education at Henry Ford. He left Henry Ford in 1997 to become the ACGME's executive director.

Retirement aspirations: To become a tour guide in Asheville, N.C.

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn