Residentsʼ Work Hours

Figure. David: C. Leach, MDI have stayed up all night lots of times. I hope and think that I have not made a serious mistake because of it. However, I do know that I felt like a zombie the next day. Every citizen on the globe has probably stayed up all night at some point—they know what it feels like. In assuring them that doctors function well when sleep deprived we are asking them to deny their own experience. It is the Achilles heel of the profession. —A distinguished senior surgeon, June 27, 2000 The health care system is broken and residents live in the cracks of the broken system. They are the glue that holds it together. —PAUL BATALDEN, MD, director, Health Care Improvement Leadership Development, Dartmouth Medical School, summer 1999 —Theme of a plenary session, group on resident affairs, chaired by Gail Warden, president and CEO, Henry Ford Health System, April 2000 These two provocative statements frame the very important issue of residents' work hours. They challenge beliefs that the primary purpose of residency is education, that the type of work performed by residents is appropriate, and that medicine's credibility is enhanced when physicians work long hours without adequate rest. Institutional and program requirements relevant to residents' work hours developed by the Accreditation Council for Graduate Medical Education (ACGME) and the Residency Review Committees (RRCs) have revealed behaviors that do little to calm the provocation. These requirements reflect the deliberation of thoughtful institutional and specialty physician leaders, all of whom are peers in their specialties and many of whom are program directors themselves. Proposed requirements are broadly circulated for comment and undergo extensive vetting. Because of this process these requirements serve two purposes: as standards against which institutions and programs can be judged and as formal statements of shared values. Each discipline has considered and adopted standards relevant to work hours, and considers those standards to reflect its values. Yet they are being violated on a regular basis. This is disturbing. Any gap between the profession's stated values and its behaviors weakens the profession. In 1999 the frequencies with which violations of work-hour requirements were cited during program reviews were 30% for internal medicine, 36% for general surgery, 29% for orthopedics, and 21% for pediatrics, to name a few. (The complete list can be found in the April 2000 issue of the ACGME Bulletin on 〈www.acgme.org〉.) The sponsoring institution is ultimately responsible for its educational programs and is charged with enforcement of the ACGME's Institutional Requirements. In 1999 the Institutional Review Committee reviewed 86 sponsoring institutions and cited 17, or 20%, for violations of these work-hour requirements. The particulars of the Institutional and Program Requirements can also be found on the Web site mentioned above. Two examples are presented here. Internal medicine's reads: II.A.2.i—k. When averaged over any 4-week rotation or assignment, residents must not spend more than 80 hours per week in patient care duties. Residents must not be assigned on-call inhouse duty more often than every third night. When averaged over any 4-week rotation or assignment, residents must have at least 1 day out of 7 free of patient care duties. In 1999 the Internal Medicine RRC reviewed 92 core programs and cited 28 (30%) as being in violation of these requirements. General surgery requires the following: V. F. Graduate education in surgery requires a commitment to continuity of patient care. This continuity of care must take precedence—without regard to the time of day, day of the week, number of hours already worked, or on-call schedules. At the same time, patients have a right to expect a healthy, alert, responsible, and responsive physician dedicated to delivering effective and appropriate care. The program director must establish an environment that is optimal both for resident education and for patient care, while ensuring that undue stress and fatigue among residents are avoided. It is his or her responsibility to ensure assignment of appropriate in-hospital duty hours so that residents are not re- quired to perform excessively difficult or prolonged duties regularly. It is desirable that residents' work schedules be designed so that on average, excluding exceptional patient care needs, residents have at least 1 day out of 7 free of routine responsibilities and be on call in the hospital no more often than every third night. In 1999 the Surgery RRC reviewed 69 General Surgery programs and cited 25 (36%) as being in violation of these requirements. These behaviors may reflect a lack of clarity about the purpose of graduate medical education (GME). I would propose that the overriding purpose of GME is to improve patient care. Being clear about the linkage between GME and patient care can do nothing but strengthen both. How do work-hour policies and practices affect patient care? Teaching hospitals attract very sick patients. These very sick patients require not just daily but frequently minute-to-minute attention by those with the best expertise. Needed are individuals who can both discern changes in the clinical situation and mobilize resources to take appropriate action. GME, properly conducted, provides an almost ideal model for such care. However, when this model is abused both education and patient care are seriously compromised. Types of abuse include abandonment of the resident, exhaustion of either the resident or the faculty, and distraction from the task at hand, sometimes by the need to focus on the system rather than the patient. Each of these forms of abuse can be sporadic or systemic. When residents are systematically, abandoned, accreditation of the residency program should be withdrawn. The environment is dangerous for both residents and patients, and sponsoring institutions condoning such behavior have failed in their responsibilities. Much more commonly the ACGME encounters supervision that while adequate is not optimal. Competing service obligations force the faculty and the residents to function more in parallel, focused on different aspects of the work before them, and less as mentors of each other. Adequate patient care is rendered, but the rich enhancement of care afforded by a true educational model is compromised. Residents tell us of teaching rounds that consist of completing documentation requirements. Creating space for dialogue between faculty and residents around issues of the care of patients is a prerequisite for the educational model, not a luxury. Exhaustion is not incompatible with good patient care, but there should be a very good reason to accept it as a normative condition. Some situations are so delicate and so complex that a tired physician who has been actively following the case offers more than a rested colleague who is unfamiliar with the patient. An intimate understanding of recent events, detection of subtle changes in the patient's condition, and monitoring the effects of a therapeutic intervention can all be enhanced by a constant observer, and at times the resident is the only constant observer that the system offers. As the Surgical Program Requirements state, there are times when “continuity takes precedence.” Yet this also can be abused. A pattern of exhaustion that is not driven by a given patient's needs but by the system's needs for someone to “cover the house” cannot be condoned. Adequate layered coverage must be available. If the profession cannot guide its behavior by its values, but instead thwarts its values to achieve convenient ends, we have indeed identified the Achilles heel of the profession. Sometimes residents themselves initiate long hours in order to become more experienced in caring for patients. The more frequently doctors do something, the better they become at doing it. For some procedures it is clear that clinical outcomes are directly related to the experience of the surgeon. Prudence dictates that residents should not be able to function independently unless they have that experience. Yet prudence also suggests that we must broaden our options for achieving this end. Working beyond exhaustion or extending the length of an already long training program are not optimal solutions. Individual learning plans for particular procedures could be developed during residency and extended beyond residency training. Simulators and virtual reality devices offer another approach. The continuum of medical education is real and does not stop at residency. Bridges between competent and proficient need to be built. Residents also tell us that they spend an inordinate amount of time getting things done. Their mantra is “It's really weird how they do things around here.” The system should make it easy to do the right thing and hard to do the wrong thing. At times the reverse seems true. Broken systems tend to distract the resident from the direct care of patients. They exhaust and frustrate needlessly. Although aware of opportunities to improve the system, residents are not empowered to do so. It is an alienating experience. Faculty may be empowered but not compelled because the resident bears the brunt of the problem. “Uncovering” a service, and asking the faculty to manage the patients for a finite period of time in the absence of residents may expose system problems and illuminate possible solutions. This experiment has been tried and in some settings has worked. Let me repeat: Whenever we act in a manner inconsistent with our values the profession is weakened. The ACGME released the data on the frequency of work-hour citations, and those data indicate that we indeed are acting at odds with our values. If we abuse our trainees and compromise patient care our status as a profession is jeopardized. The solutions call for co-operation between CEOs and deans, between department chairs and program directors. The requirements don't need to be rewritten, they need to guide our behaviors. Meanwhile the ACGME will continue to monitor and publish its observations, and repetitive patterns of work-hour violations will result in adverse accreditation actions.