A work in progress: Reshaping residency

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.