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Work hour rules rile educators—and residents

Forced to watch the clock, some housestaff say they feel 'cheated' out of chances to learn

From the October ACP Observer, copyright 2003 by the American College of Physicians.

By Bonnie Darves

Talk to Donald E. Girard, FACP, about the rules that now regulate his residents' work hours, and he gives a mixed—and increasingly typical—response. "Anecdotally, what I've heard from our faculty is, 'The residents are leaving on time, but now I'm working 100 hours a week,' " said Dr. Girard, director of graduate medical education at Portland's Oregon Health & Science University (OHSU).

Three months after the Accreditation Council for Graduate Medical Education (ACGME) implemented its new work hour rules for residents, program directors across the country are wrestling with staffing shortages and scheduling hardships as they adjust to a new role: time-clock monitors.

Many are instituting elaborate night-float programs and finding new ways to schedule housestaff. Others say they may have to cap the number of patients on some services—and move certain types of patients off teaching services altogether.

ACP continues to firmly support the new rules. (The College's 2003 position paper on resident work hour rules is available online.) But educators are grumbling about problems implementing the rules, while a number of residents—the very people the rules were designed to help—say they too are chafing under the new requirements.

Several residents interviewed for this story said they feel they're being cheated out of valuable time with patients. When housestaff have reached the end of their "shift," for example, many are feeling pressured to leave the hospital—or risk jeopardizing their program's accreditation.

Fewer educational opportunities

Like other internal medicine training programs, OHSU is struggling not so much with the 80-hour workweek—which internal medicine has been living with since the late 1980s—but with the new "24+6" rule.

Under that new rule, residents can perform no more than 24 hours of continuous duty time, followed by a six-hour "grace period" for care-continuity tasks or educational activities. Confounding matters is the fact that residents must now have at least 10 hours off between duty periods. (For more on the rules, see "New work hour rules: Are they too inflexible?")

Educators say that these new standards are forcing some residents to miss out on educational opportunities such as traditional morning report or clinic duty. Presbyterian Hospital in Dallas, which began changing its resident work hours long before the July 1 deadline, found it had to adjust educational activities and housestaff schedules to make the new standards work.

Mark Feldman, FACP, Presbyterian's internal medicine program director, said that attendance at educational conferences post-call is now voluntary, not mandatory, and that the conference has been moved from 12:30 p.m. to noon so residents can leave the hospital before going over their hours limit. Post-call teaching rounds now are also optional, while the program is using sophisticated e-mail systems to help better manage sign-outs and patient hand-offs.

Even with those changes, the hospital is still wrestling with potential coverage gaps. As a result, educators are looking at instituting a new day float to cover residents who must sign out at 1 p.m.

"The 80-hour work week is a reasonable goal, but I would like to see some flexibility" in the 30-hour limit, Dr. Feldman said. "We're in much better shape than many programs because we have hospitalist physicians who can help, but this hasn't been good for training."

Some hospitals have learned that the new rules require residents to sign out earlier in the day so they have time to write notes, order tests and procedures for patients, and generally prepare to hand the patient off to the next resident. At OHSU, for example, housestaff on duty after call now sign out at noon or 1 p.m. at the latest, said Thomas G. Cooney, FACP, director of OHSU's 90-resident internal medicine residency program.

"It became abundantly clear early on that we had to push that time back," he explained. "Even with that, we find we have to almost sequester the residents to make sure they can finish writing their notes and not be exposed to the tension of feeling they're ignoring issues with patients."

Some educators also say the new rules have made the learning environment less flexible. "People are learning and teaching and paying attention," Dr. Cooney added, "but what's missing is that sort of dwell time, when residents would sit around the table and put their feet up and talk, without facing a time clock."

And while programs are busy measuring their compliance with the new work hour limits, "what's not being measured is what is being lost in the aggressive effort to be in complete compliance," he continued. "I absolutely support these changes, but we're not set up to figure out whether there will be adverse effects that alter the quality and experience of medical education."

Scheduling headaches

For Robert E. Wright, FACP, director of the 22-resident Scranton-Temple Residency Program in Scranton, Pa., the 30-hour rule has created a scheduling nightmare. Because so many of the program's residents are in a primary care track, they tend to have more clinic assignments than their counterparts in other academic programs. In addition, Dr. Wright's program staffs an ICU and four clinical services in separate hospitals.

"The complexity has been enormous," he said. "Ensuring coverage and also ensuring our residents get to their afternoon clinics has been difficult. It's taking a fair amount of creative scheduling." He added that surviving the new rules would be "impossible" without Scranton-Temple's computerized scheduling program.

Educators at Louisiana State University (LSU) Health Sciences Center in New Orleans, which has 98 residents, have similarly found scheduling residents and complying with the new rules to be a challenge. Scheduling residents is now nearly a full-time job for Shamita Shah, ACP Associate, the program's chief resident and a member of ACP's Council of Associates.

"As time goes on, I'm figuring it out," she said, "but right now I am spending almost 100% of my time scheduling." Problems include creating workable schedules to ensure that all residents get clinic time—and that the clinics are properly staffed.

Dr. Shah said that monitoring internal moonlighting to avoid schedule conflicts or overload has also proved particularly difficult. While LSU residents are permitted to moonlight at the hospital's facilities, the new rules count internal moonlighting as part of residents' workload for that hospital.

While many program directors say they support the new rules' objectives—a better-rested resident workforce providing safer patient care, and future physicians with a healthier work-life balance—they resent the intrusion into how they run their programs.

"I hear more complaints from program directors about micromanagement than the global principles," said Lawrence G. Smith, FACP, past president of the Association of Program Directors in Internal Medicine and dean of the Mount Sinai School of Medicine in New York. "People believe 80 hours is more than enough work, but the 30-hour rule and the 10-hour rest rule limit your ability to create a smooth schedule. That's what is making people crazy."

Dr. Smith said the standards have also created new stresses for Mount Sinai's 130 internal medicine residents. "It's very difficult now to get people to feel comfortable in the transition of care," he said. "Everybody feels rushed and stressed because the clock is ticking."

At Mount Sinai, most residents got out on time even under the old system of New York state rules, Dr. Smith explained. (Residency programs in New York were forced to institute 80-hour duty hour limits after the well-publicized 1984 death of teenager Libby Zion, which was later attributed to resident fatigue.) But he claimed that New York's rules were not nearly as rigid as the new ones, which carry a big stick in the form of losing ACGME accreditation.

"In the old system, when residents had a bad day, they didn't feel like somebody had a gun to their head forcing them to leave the hospital within a certain time," he said. "Now, if anyone even sees residents in the hospital after the hours limit, it's like they're being grabbed by the collar and thrown out on the street."

'Something missing'

Several of the residents interviewed for this story expressed similar sentiments about the new rules. Second- and third-year residents in particular have complained that "there's something missing" in their educational experience, said Scranton-Temple's Dr. Wright. "There are a lot of residents who think they're being cheated."

At Presbyterian Hospital in Dallas, for example, some residents have complained of being rushed after taking a call night. "The residents know the rules were put in place to reduce stress, work hours and errors, but they're feeling like Cinderella with the clock ticking," said Dr. Feldman. They also feel extra pressure to get work completed, "because if they sign out the patient to someone else, something might be lost in translation.

"Our faculty work until their job is done, and that's the model residents are used to," he explained. "When 1 p.m. comes around and residents are forced to leave in the middle of seeing a patient or checking lab results, they don't want to sign out."

While few residents quibble with the new standards' intent—to make sure they receive adequate rest and to protect patient safety—some resist what they also view as micromanagement of their work.

"I don't like the new restrictions because I feel as if I'm missing something—and I don't like having people tell me I have to go home," said Lee S. Engel, ACP Associate, a third-year internal medicine resident at LSU. "I want to take care of my patients, and when I feel the work is done, I go home. Now it's a bit like punching a time-clock—and it's extra paperwork."

Dr. Shah said one loss, from a learning perspective, is that the program has cut out its Thursday morning report and substituted it with grand rounds. Residents couldn't attend both and still leave the hospital before their 30 hours were up.

"A lot of things we discussed in morning report—and what I saw in those late post-call cases—were on my boards," Dr. Shah said. Residents who come into the program after her may not have some of those opportunities that she had to learn.

Better-rested residents

On balance, however, Dr. Shah said the new rules confer definite advantages. "It makes for happier residents, better rested residents," she said. "I'm sure patient care has been positively affected to some extent because the residents are fresher."

Sara Wasserbauer, ACP Associate, agreed that the rules have improved some aspects of her life. The third-year resident at Exempla St. Joseph Hospital in Denver said that since her department added night float to comply with the rules, she spends fewer overnights in the hospital. She added that she and her fellow residents are more rested and balanced.

"Despite the growing pains and the adjustment, I think everyone is more positive than I've seen them in the past," said Dr. Wasserbauer, who is a member of ACP's Council of Associates. "We recognize the limits of the human body in our patients, if not in ourselves—up until this point anyway," she said with a laugh.

According to Dr. Wasserbauer, the rules have produced other positive effects. Residents must now act more strategically in structuring their days and handling tasks. For example, they must start planning well ahead for the "hand-off" of patients.

"When I'm in the ICU post-call and I know I have to be out by 1 p.m., it forces me to think like a chess player: one step ahead," she explained. "If I have a patient who might be going home in two days, I start thinking about home care issues and physical therapy sooner. This actually hones my ability to be an adequate internal medicine physician."

Still, Dr. Wasserbauer acknowledged the rules' downsides, like the possibility of missing out on important patient-status developments and related responsibilities. She recalled one patient who "crashed" in the ICU at 5 a.m. and later died. Because the new work hour rules had not yet taken effect, she was able to stay with the patient until the end.

Under the new rules, however, she would have had to hand the patient off to someone else. "If I hadn't been able to have that closure with the patient's wife, it would have been terrible," she said.

Even in New York, where more stringent work hour regulations have been in effect since the 1980s, the added wrinkles of the new rules are forcing internal medicine programs to make adjustments. David M. Donaldson, ACP Associate, chief resident at North Shore University Hospital in Manhasset, said residents have complained that the rules' inflexibility is causing continuity-of-care problems, even when night floats are well established.

"Residents say they feel like shift workers, spending more time delegating responsibility and less time looking after their own patients," he said. "That's the sacrifice, but at the same time they're more refreshed."

Necessary evil?

While many aspects of the new rules trouble program directors and residents alike, many say they are preferable to a potential alternative: federal regulation. Last year, a bill was before Congress that would charge the government with regulating resident hours, a prospect that makes medical educators nervous.

"The ACGME rightly believed that in the long run, the profession would be better off regulating itself than having laws passed," said Mount Sinai's Dr. Smith. "The standards it came up with were in response to what most people felt were the minimum acceptable political solution."

According to Dr. Donaldson, whose father is a physician, the changes were necessary, but for entirely different reasons. "Years ago, residents were taught that the best way to do medicine was to do more of it," he explained. That mindset fostered a culture, he said, in which you weren't considered to be a good doctor unless personal concerns were sacrificed to your medical life.

"People are starting to see that doctors are people, that in order to relate to your patients you have to have a balance in your life," Dr. Donaldson added. "The new regulations are just keeping up with what's going on in the real world."

OHSU's Dr. Girard said he is confident that program directors and residents will work through the challenges, and that medical education won't suffer unduly. "We will adjust," he said. "These [hour limit] requirements have been around in medicine for a long time, and a lot of innovation—night float rotations, for example—has taken place to get ready for where we are today."

He also finds no value in comparing the "old days" of internal medicine education with the new world, because there's little common ground between the two.

"I still hear from older faculty that 'when we were residents, we were really tough and we were on call every other night,' " said Dr. Girard, who turns 60 this year. "But the level of sophistication and complexity of care then doesn't even begin to compete with what we have now. It's apples and oranges."

Bonnie Darves is a freelance writer in Lake Oswego, Ore.

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New work hour rules: Are they too inflexible?

Program directors and residents claim the 80-hour workweek limit included in the new Accreditation Council for Graduate Medical Education (ACGME) guidelines isn't causing them many headaches. After all, internal medicine has lived with that limit for 14 years, even though programs up to now have had some flexibility to ensure coverage or allow residents to take a care process to its natural conclusion.

Instead, they say the problem is the strict and inflexible enforcement of duty-hours limits, with the attendant risk of losing program accreditation if compliance isn't achieved—a hammer the ACGME has already used to penalize Baltimore's Johns Hopkins University for work hour violations in its internal medicine residency program.

Here is a summary of the new standards, which went into effect July 1, 2003:

  • Resident workweeks can no longer exceed 80 hours, averaged over four weeks. Starting July 1, 2004, programs may request a 10% increase, provided the educational rationale meets the ACGME's criteria.
  • Continuous duty time must not exceed 24 hours, although residents can work an additional six hours for care-continuity or educational activities. This has become known as the "30-hour limit."
  • Residents can take in-house call no more than once every three nights, averaged over four weeks. In addition, in-institution moonlighting now counts toward the weekly work-hour limit, and program directors must ensure that external and internal moonlighting don't interfere with educational goals and objectives.
  • Residents must now have 10 hours of rest between duty periods, and one in every seven days must be free from all patient care and educational activities.

Ingrid Philibert, ACGME's director of field activities, acknowledged that some of the new standards—especially the 24+6 rule—are causing difficulties for some internal medicine programs.

To help programs share solutions, the ACGME has posted several documents on its Web site with answers to commonly asked questions and articles on the rules and issues for residents.

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