Teaching doctors: Fewer hours mean less learning

Internal medicine physicians who train residents say duty-hour limits have hurt future internists' patient care involvement, bedside learning and physician-patient relationships.

The national survey of 154 clinical faculty representing 39 programs also found that since the 80-hour work-week limit took effect in July 2003, it has improved residents' well-being but also increased faculty workloads and decreased their job satisfaction.

Steven Weinberger, MD, senior vice president of medical knowledge and publishing for the American College of Physicians, agreed with the findings published in the July 23 Archives of Internal Medicine. But he emphasized that implementing major changes can be a tumultuous process.

"The solution is not to bag the work hours, but what do we do to redesign training within the work hours," Dr. Weinberger said.

Study lead author Darcy Reed, MD, MPH, sees the findings as a tool to drive positive change, such as transitioning from the old model of one resident per patient to team-based care.

Among the findings, 87% of faculty surveyed said residents' continuity of care declined after duty-hour limits. Dr. Reed, an assistant professor of medicine at the Mayo Clinic College of Medicine in Rochester, Minn., suggested that faculty who trained under the traditional model would expect residents to be available to meet patients' needs as they arose, which implies working excessive hours. If faculty considered continuity in terms of a team, then high-quality care could still be provided without an individual resident's constant presence.

The ACP's Dr. Weinberger said efforts are under way to create such models. Twenty-one internal medicine residencies are participating in the Accreditation Council for Graduate Medical Education's Educational Innovations Project, which emphasizes residency redesign. Ultimately, all programs should have access to their results.

Also, the Residency Review Committee that oversees internal medicine training is set to review these requirements soon and will likely consider studies like Dr. Reed's during the process, Dr. Weinberger said.

Factors other than duty-hour limits also are contributing to the loss of resident autonomy and declining job satisfaction among physician faculty, according to Barbara Schuster, MD, professor of medicine at Wright State University Boonshoft School of Medicine in Dayton, Ohio.

"A slow erosion has taken place over these last 10 to 15 years," Dr. Schuster said. Safety and quality requirements are moving teaching clinicians out of their arms-length supervisory role into that of responsible physician, with residents looking on.

The supervising physician is increasingly being held responsible for patients' length of stay, cost of care, accuracy of resident dictation and significant documentation additions to residents' patient notes, said Dr. Shuster, who contributed an Archives editorial on Dr. Reed's study.

Improving resident training, she said, requires not just redesigning residency but looking at the bigger picture.

While the study results could be generalized, in part, to other specialties, Dr. Reed said, the survey focused on internal medicine educators.

"These are the physicians on the front lines, who witness the duty hours impact," Dr. Reed said. "They're important stakeholders."