In the three years since the Accreditation Council for Graduate Medical Education (ACGME) instituted duty hour standards, academic and community-based internal medicine (IM) residency programs have had to change the way they do business. Although several surveys have documented residents’ satisfaction with reduced duty hours, some program directors and medical directors are concerned that complying with the standards can contribute to faculty burnout, affect continuity of patient care, and diminish residents’ educational opportunities. In recent interviews, IM program directors and medical directors of hospital medicine services shared their challenges of complying with the standards.
Who Takes Care of Patients?
The major provisions of the ACGME Common Duty Hour Standards, which took effect July 1, 2003, call for a weekly work limit of 80 hours, averaged over four weeks; a 24-hour limit on continuous duty time, with an additional period of as many as six hours to allow for continuity of care and educational activities, referred to as the “30-hour rule”; one day in seven free from all patient care; in-house call no more than once every three nights; and a 10-hour rest period between duty periods and in-house call. For more information on the new standards, visit www.acgme.org.
By instituting decreased duty hours, the council aimed to ensure that residents would be well rested, medical errors would be reduced, and patient safety would be improved. Tom Baudendistel, MD, associate residency program director at California Pacific Medical Center, a community-based hospital in San Francisco operated by Sutter Health, believes, however, that at the administrative level, the standards create “a potential for residency programs to be at odds with hospitals’ missions. Residency is making less money for the hospitals: For the same amount of dollars, they are receiving less coverage. So, hospitals hire additional attending physicians and physician extenders, which are a lot more expensive.”
With residents less available for extended duty hours, one of the largest challenges is to “figure out who’s going to take care of the patients,” notes Daniel Dressler, MD, MSc, director of the Hospital Medicine Service at Emory University Hospital, Atlanta. “At least in our institution, hospital medicine has stepped in to provide that care for many of the patients. We cannot get any additional house staff, and because their hours have been cut—reasonably so—we’re having to fill in the necessary gaps.”
The same phenomenon has occurred at Virginia Commonwealth University, Richmond, where Alan Dow, MD, MSHA, is assistant professor of Internal Medicine and director of the Academic Hospitalist Service. “My group has gone from two physicians four years ago, to now having 15 physicians,” he said recently. “We’ve grown, in large part, because we’re making up for the residency caps, but also because we’ve found other roles for ourselves in the health system to contribute and help.”
Another effect of decreased duty hours has been to contribute to the advent of non-teaching services, notes Dr. Baudendistel and Arpana R. Vidyarthi, MD, assistant professor of medicine and director of Quality-General Inpatient Medicine, University of California, San Francisco. At a recent panel she conducted at the SHM annual meeting, Dr. Vidyarthi said the main reason panelists cited for instituting non-teaching services was to reduce workloads for residents and comply with duty hours standards.
—Arpana R. Vidyarthi, MD
Maintain Continuity of Care
The resident work hour caps have created a kind of mismatch with daily hospital routines, says Dr. Dow. In the ideal world, residents could admit patients at 7 or 8 a.m., allowing ample time to perform a comprehensive history and physical, review patients’ tests results, synthesize all the information in an educational way, and then be able to leave at 5 or 6 p.m. that evening. “Unfortunately,” he says, “patients show up at 4 or 5 p.m., until about 8 or 10 p.m., depending on the day. Ideally, we would have the same person admit and discharge the patient, but that just isn’t feasible because of the work hour caps.”
At Virginia Commonwealth, Dr. Dow’s hospitalist group has found that assigning admitting duties and ongoing patient care to separate teams allows for better patient care. Designated admitting physicians handle the admitting work in the late afternoons and evenings when most patients come up to the floor. All of the patient care is then transferred to another group of physicians who work during the day, ordering tests, speaking with consultants, and talking with families and social workers.
“What we’ve done is try to focus on continuity from that second day of hospitalization until discharge,” says Dr. Dow, “because I think the most critical point for errors in care is at discharge. We want to make sure that by the time patients go home, the discharging physician and the rest of the group have a really good idea of what is going on with those patients: What kind of home situation are they going to? What kind of follow-up do they have? What kind of medications are they going to be on? What kind of home services will they need?”
Dr. Dow has also noticed that reduced resident hours have resulted in the necessity for faculty to be more “available and present, and to focus on making the team more efficient. For my group of hospitalists, this is not a problem because our clinical venue is the hospital. But for people who are active researchers or who need to go to other clinical venues, this can be very difficult because their obligations in the hospital are more than they were five years ago.”
Casualties of Caps
No one argues that decreased duty hours are a bad idea. As a consequence, however, more work has fallen to faculty. Because residents have to be out of the hospital at designated cut-off points, attendings must stay up-to-speed with nuances of paperwork and electronic medical records. Sources agreed that they have observed faculty members working harder and harder, and many worry about issues with potential burnout among the faculty.
“As duty-hour decreases have changed the nature of the academic hospitalist’s job, this leaves less and less time to do not just the things that you may enjoy and find intellectually satisfying, but also the things that are expected for getting promoted—a necessary part of life as an academic hospitalist,” says Dr. Vidyarthi.
Other program directors voiced concerns that certain provisions of the duty standards might foster less connection to both the treatment team and to patients. “I think the fear I have as an educator,” says Dr. Baudendistel, “is the erosion of the continuity and the professionalism that is a byproduct of the work hours decrease, with the implicit hand-offs that occur in care. This is a paradigm shift. When I was a resident, this was my patient because I didn’t have too many days off. I saw my patient through the long hospitalization.”
But with changes in the duty hours, he says, now “the residents with reduced work hours and mandated days off might only admit the patient. Then three other house staff will see the patients and discharge them, and it’s not their patient any more. Who’s there to provide the continuity? It’s the attendings. So then the residents can abdicate responsibility to the senior residents and the attendings because they are only at the hospital for, say, a 12-hour shift.
“I think that shift work mentality is a definite threat to professionalism,” he concludes. “And that mentality is not good for patient care.”
Studies of Standards’ Effects
Few studies have been published specific to the hospital medicine experience with the reduced duty hours. Lin, et al., conducted four focus groups of internal medicine residents at the Washington University School of Medicine (St. Louis, Mo.), and found concerns about the effects of the duty hour restrictions on patient care and medical education.1 A study published this January in Academic Medicine by Dr. Vidyarthi and colleagues at UCSF asked 164 internal medicine residents to rate the value of their educational activities, frequency of administrative tasks interfering with education, and their educational satisfaction after duty hours were reduced.2 Dr. Vidyarthi and her coauthors did not see an increase in educational satisfaction, which was one of the expected outcomes of the new duty hour restrictions. She believes that for educational satisfaction among residents to increase, additional structural changes also must be put in place.
“If this is really an educational endeavor, then we need to make it such,” she says. “Duty hour decreases are here, so let’s make this amount of time that [the residents] are spending in the hospital as educationally valuable as possible.”
Can Less Be More?
One effect of reduced resident availability is that hospital medicine programs must become more thoughtful about the content of the educational experience for residents. If residents will see fewer patients because of fewer hours on duty, how might the remaining patient contacts be maximized for their educational opportunities?
“I think that there is much room for making their time in the hospital as educationally valuable as possible,” asserts Dr. Vidyarthi, “from pedagogical ways of thinking about medicine, to decreasing the number of tasks that they do that are not educational in value.”
Dr. Dressler agrees. “By reducing the resident work hours, we definitely reduce the amount of patient contact by residents,” he says. “Now, whether or not that will dramatically affect the amount of education the residents receive would be difficult to measure. Potentially, down the road, the American Board of Internal Medicine or some other governing board may decide that residency programs need to be longer. Medical training programs have instituted a comprehensive programmatic change [with the new work hours], will attempt to evaluate all the potential downsides as well as the value of this change, and, ultimately, will have to address problems or unexpected results in the new system in order to optimize patient care as well as physician trainee education.”
At California Pacific Medical Center’s residency program, “there are certain components we have had to re-analyze, and consider. [For example,] what is our core educational mandate that we’re trying to achieve? ” asks Dr. Baudendistel. Examining residents’ rotations, he says, has led to decisions to take residents off certain rotations, such as transplant nephrology, in favor of less esoteric rotations.
Hospitalists to the Rescue?
The question remains whether the reduced duty hours are better from the patient’s point of view. “The number of sign-outs that we’re seeing due to the duty hour decreases is significant. Interns will sign out approximately 300 times in a month, which is more than the number of patients they’ll see in the course of a year and, in fact, more often than they will eat in a month,” says Dr. Vidyarthi. “So, the challenge for the safety of patients [one of the impetuses for the decreased duty hours] is being balanced against having better rested, potentially better educated, happier residents. It’s really a Faustian bargain. Are we making this bargain [for better-rested residents] such that patients will, in fact, not be safer, because of the sign outs?”
Concerns about continuity of care under the new standard are “reasonable and legitimate,” says Dr. Dressler. “From a hospital medicine standpoint, that is how we practice: We are frequently handing off care. We understand that there is an inherent potential risk of doing that, and we like to be able to teach and train residents and students to understand how to do that effectively as part of their practice. Because hospitalists do this daily, we have an understanding of how to train people to optimally handoff patients to other clinicians and/or transition patients to other care settings or the outpatient arena.”
Dr. Dow views his hospitalist group as a sort of a “free safety,” taking care of patients that residents may not be able to take care of. “I view hospitalists as problem-solvers. Whether it’s a specific patient with a medical or social need, or a system problem, our big role is in filling those needs,” he says. “When patients need to be admitted and no other group is available, my hospitalist group is ready to care for folks.” TH
Gretchen Henkel is based in California.
- Lin GA, Beck DC, Garbutt JM. Residents’ perceptions of the effects of work hour limitations at a large teaching hospital. Acad Med. 2006 Jan;81(1):63-67.
- Vidyarthi AR, Katz PP, Wall SD, et al. Impact of reduced duty hours on residents’ educational satisfaction at the University of California, San Francisco. Acad Med. 2006 Jan;81(1):76-81.