Clinical and Health Affairs
Impact of New Duty-Hour Rules on Residency Training
By Alisa Duran-Nelson, M.D., Joan Van Camp, M.D., and Louis Ling, M.D.
Abstract
On the surface, changing the rules related to the number of hours residents work per day and per week sounds like a good idea. Theoretically, residents who work fewer hours would be less tired and provide better patient care. But even small changes in residency training programs have implications for the quality of the educational experience and the cost of training, as well as patient care. This article highlights the challenges that two Minnesota residency programs are facing as they adapt to the new rules around residents’ work hours.
Residency has long been a rite of passage for young physicians. Famous for requiring them to work long hours and spend sleepless nights hovering over critically ill patients while learning to handle the stress and strain of becoming a “real” doctor, it has often been the stuff of legends. The term “house officer” arose because residents were expected to live at the hospital. All this might have continued, except that around 2000, with new notions about patient safety surfacing, concern arose about sleep-deprived residents making errors that might put patients at risk.1 It made sense that if truck drivers, airline pilots, and railroad engineers were prevented from working overly long hours for the benefit of public safety, physicians ought to be prevented from doing so as well because their work was even more critical and prone to error. Advocacy groups such as Public Citizen demanded reforms in order to prevent patient deaths.
In 2003, in response to the public’s concern, the Accreditation Council for Graduate Medical Education (ACGME) put into place the first duty-hour limits, establishing the maximum number of hours a resident could work in a week (80 hours per week averaged over four weeks), limiting the length of call to 24 hours with a six-hour hand-off period to transfer care, limiting call to every third night on average, and giving residents an average of one day off per week.
Residency programs made changes: They instituted night float systems, hired hospitalists, and increased the number of handoffs. But they still struggled with the rules. Meeting the requirements seemed an end in itself, and counting hours was a distraction from teaching. Then in 2008, despite the lack of evidence that safety actually improved with the changes,2 the Institute of Medicine (IOM) concluded that even more stringent restrictions, including mandated naps, were needed.3 The response from many physicians was mixed, with some expressing concern that medicine was being forced to adopt a shift-work mentality.
In response, the ACGME underwent an 18-month process of gathering testimony before proposing new rules in June of 2010. Although the new rules, which are to be implemented by July of 2011, are stricter than the ones implemented in 2003, they are not as stringent as the ones suggested by the IOM.4 The new rules rightfully focus on patient safety rather than on the number of hours worked, and they call for placing progressively increasing responsibility on residents each year they are in the program. Although the 80-hour limit remains unchanged under these rules, first-year residents will no longer be able to work more than 16 continuous hours. More senior residents can be on call for 24 hours, but they will have to complete handoffs within four hours instead of six, and residency programs will be required to investigate every exception. In addition, hours spent moonlighting will count toward the 80-hour limit.
A national survey found that more than 90% of residency program directors approved of the new rules with regard to time off, workload, and moonlighting but that about 85% disagreed with the change to a 16-hour work-day limit for residents in their first year. Program directors expressed concern about more handoffs taking place, the loss of educational opportunities, the cost, and the loss in terms of a sense of professionalism and responsibility.5
As programs work to implement the new duty-hour rules by the 2011 deadline, they are grappling not only with how to cover shifts and staff hospital units but also with how they can improve the training of physicians. This article describes the efforts of two Minnesota programs as they work to make the required changes. It illustrates some of the challenges these programs face and discusses issues the changes raise.
Internal Medicine at the University of Minnesota
In internal medicine, the duty-hour restrictions have come at a time when there also has been an increased focus on patient safety and quality improvement as well as new requirements for more stringent documentation of everything in medicine. As a specialty, we have set appropriate boundaries for our trainees in terms of total work hours, sleep time, and days off. We also have more insight than ever into the effects of sleep deprivation and the limitations of our trainees.
The University of Minnesota’s internal medicine residency program has met the requirement for an 80-hour work week with one day off in seven at its three hospital training sites without much difficulty. We plan to meet the new requirement that prohibits first-year residents from working more than 16 consecutive hours by passing more of the patient care on to senior residents, staff, and physician extenders. This introduces the idea of giving residents progressive responsibility during their training, and it marks a big change, as we traditionally front-loaded responsibility by having first-year residents spend the bulk of their time in the inpatient setting so more senior residents could spend more time doing electives.
Five years ago, we established a night float system in order to eliminate overnight call for all medicine residents. We gradually reinstated some overnight call at the request of residents who disliked having to hand off care of their patients to physicians working the night shift. With the new requirements, we will have to strike a balance between meeting our residents’ desire to provide continuous care and our professional obligation to provide the highest quality care to patients. Clearly, more of the patient care responsibility will have to shift to staff physicians and physician extenders. The new requirement that senior residents can only be on-call for 24 consecutive hours plus a four-hour transition period also will be a challenge to implement. Residents at tertiary care centers already feel stressed when they have to leave very complex patients such as those undergoing transplants, with end-stage heart disease, or with late-stage or rare cancers in the care of others. Ironically, shorter work hours may cause more stress for those physicians who want to be there for their patients. In some cases, they see patient handoffs as being counter to the oath they took to become a physician.
The biggest challenge for the University of Minnesota has been establishing a 10-hour free period between shifts, which was required by the 2003 rules, as residents felt it interrupted the continuity of care they could provide. Thankfully, the new rules allow for some flexibility such as allowing for an eight-, rather than a 10-hour break.
To determine how to best restructure our call system, the university’s medicine program will hold a duty-hour summit that will include residents, program directors, and rotation directors. At this point, we do know that we will have to add mid-level providers to some services in order to meet both the ACGME requirements and our patient care needs. We also plan to add a swing-shift physician to the inpatient medicine service at the University of Minnesota Medical Center, Fairview to help manage the influx of patient admissions that occurs in the late afternoon and early evening. We anticipate hiring more hospitalists to help manage the inpatient census at both the University of Minnesota Medical Center, Fairview and Veterans Affairs Medical Center sites, and we are recruiting nocturnists to work at the university site. We have an outstanding model in our academic hospitalist program at Regions Hospital, which uses dedicated teaching hospitalists to provide care in conjunction with residents. It allows us to easily comply with the current ACGME work-hour rules at that site. Additionally, we are working to streamline patient care at the University of Minnesota Medical Center, Fairview in order to increase resident efficiency. Our ward director has been part of an innovation team that includes health care professionals from multiple disciplines who are working hard to improve efficiencies and provide more patient-centered care.
Our approach to education will need to change as well, as residents will spend fewer hours in the hospital learning than in the past. Many skeptics say that it will be only a matter of time before we will have to increase the length of the training programs in order for residents to learn what they need to know. This may not be necessary if we can be innovative. Already, we have started using web-based technology to deliver rotation curriculum to our residents in the form of PowerPoint presentations, case studies, and video tutorials about procedures and examinations in order to allow them to learn at their convenience. We are slowly moving toward portfolio assessment, which takes a broader view of residents’ learning, in order to more accurately assess their competence. (The ACGME Milestones Project is helping us define measures of competence.) In a sense, we are using the changes in the duty-hour rules as an opportunity to make positive changes in resident education.
Surgery at Hennepin County Medical Center
Currently, the surgery staff at Hennepin County Medical Center (HCMC) is managing the care of some patients without resident involvement. A survey done in 1997 showed that HCMC surgery residents were even then working an average of 78 hours a week. They were taking two to three days off a month, and they were taking call every fourth night. Although it appeared only minor changes would be required to comply with the 2003 ACGME work-hour restrictions, meeting the requirements proved to be more difficult than anticipated. As a group, HCMC residents were not working more than was allowed, but there was great variation among individual residents and individual services. One reason for this is the unpredictable nature of trauma and emergency surgery. Staffing each of those services with enough residents to provide coverage, not overwhelm new residents with responsibilities, and still adhere to the work-hour restrictions proved to be a daunting task.
Moving to the 80-hour work week in 2003 required scheduling all conferences on weekday mornings rather than in the afternoons or on weekends, thus eliminating some weekend and late-afternoon hours from residents’ schedules. “Nonessential” rotations in private hospitals have been eliminated to implement the one-day-off-a-week rule and ensure that residents are not taking call more than once every third night. Residents also have had to become more flexible so that they can cover for one another. The curriculum now emphasizes the teaching of sign-out skills for transferring care of a patient to another physician, and more staff oversight of these transfers is required in order to assure patient safety.
The 24-plus-six-hour shift limit rule has been the most difficult one to comply with. A cultural change was needed to get residents to leave the hospital once they finished with call, trusting that other staff would provide continued coverage in the OR and clinic. Residents, who before may have slept until 6 a.m. now get up as early as 4:30 or 5 a.m. to get a jump on writing daily notes or morning orders so that they are done with their duties within the time limits. Nurse coordinators have been assigned to each service to help residents be more efficient with discharge plans, and surgery staff now make early morning post-call rounds with residents as opposed to rounding later in the day.
We have squeezed our program to comply with the ACGME work-hour restrictions, thus there is not much more we can do to meet the more stringent work-hour restrictions called for in 2011. First-year residents, who will be limited to 16-hour shifts, will directly feel the effects of the changes. But so will senior residents, who will be expected to take up the slack for being on call and doing handoffs even though their 24-plus-six-hour shift limit will be decreased to 24 plus four hours.
Currently, the surgery staff at HCMC is managing the care of some patients. Our concern is that if this continues, the educational mission of our hospital will be diluted. HCMC plans to hire physician extenders such as physician assistants and nurse clinicians to provide some of the care residents once delivered. One idea is to have three mid-level providers. Two would assist residents with post-call routines such as confirming final X-ray readings on trauma patients or completing discharge paperwork and orders. The third might be assigned to the surgical ICU, where he or she would assist residents with routine orders and protocols. These physician extenders would help residents become more efficient at providing routine care for surgical and trauma patients. This would allow residents to concentrate on more unusual or complex cases. Although it will take an investment on the part of HCMC to bring on physician extenders, doing so will outweigh the costs, as they will generate revenue and increase efficiencies.
Conclusion
Resident training programs face many challenges today. Programs in all specialties have to strike a balance between doing what is best for resident education and doing what is best for patient care. The medicine program at the University of Minnesota is planning to become more flexible and innovative as it adapts to the new resident duty-hour rules; it may use physician extenders and grow its hospitalist program to manage the increasing patient census. Similarly, HCMC’s surgery program has had to be flexible in order to make the changes required by the current duty-hour regulations; it too will likely need to rely on physician extenders and other mid-level providers to supplement the resident teams.
It is clear that limiting work hours has changed the resident training experience, increased the work of faculty, and increased the number of patient handoffs. Continued changes have the potential to decrease resident fatigue, make learning more focused, and improve the resident experience. They also may lead to less-fragmented patient care and educational experiences. The new rules are here to stay. It is up to us to find ways to comply with them that result in the best possible patient care and physician education. MM
Alisa Duran-Nelson is an assistant professor of medicine and program director of the internal medicine residency program at the University of Minnesota. Joan Van Camp is an assistant professor of surgery at the University of Minnesota and program director of the Hennepin County Medical Center general surgery program. Louis Ling is professor of emergency medicine and associate dean for graduate medical education at the University of Minnesota and associate medical director for education at Hennepin County Medical Center.
References
1. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Institute of Medicine. Washington DC: National Academies Press, 2000.
2. Volpp KG, Rosen AK, Rosenbaum PR, et al. Mortality among hospitalized Medicare beneficiaries in the first two years following ACGME resident duty-hour reform. JAMA. 2007;298(9):975-83.
3. Ulmer C, Wolman DM, Johns MME, eds. Resident duty hours: enhancing sleep, supervision, and safety. Institute of Medicine. Washington DC: National Academies Press, 2008.
4. Nasca TJ, Day SH, Amis ES Jr. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2): e3.
5. Antiel RM, Thompson SM, Reed DA, et al. ACGME duty-hour recommendations—a national survey of residency directors. N Engl J Med. 2010;363(8):e12.