A medical residency is no walk in the park. For a resident, there are no weekends, and working 9 to 5 is a half-day. Working overnight is routine – every 3 or 4 nights on some rotations – and entails more than just the “graveyard shift,” as a typical on-call shift can run from 7 in the morning to 1 in the afternoon…the next day.
In 2003, pushback from patient groups and politicians led the Accreditation Council for Graduate Medical Education (ACGME), the body that oversees U.S. residency programs, to institute limits on duty hours. Residents were restricted to working 80-hour weeks, limited to 24 hours of continuous care (with a 6-hour extension allowed for some activities), and were supposed to receive an average of one day off for every seven days.
Hospitals initially struggled to adapt to the new restrictions, redrawing schedules and hiring support staff to cover for the missing resident hours. But just when things were settling down, another round of restrictions is growing imminent, this time fueled by studies showing that being awake for longer than 16 hours is equivalent to having a blood alcohol level of 0.05 percent. Last year, the Institute of Medicine recommended that residents be restricted to 16-hour shifts, or be required to take a mandatory 5-hour nap if they work more than 16 hours. The panel also recommended additional supervision, particularly of interns, the first-year residents just out of medical school.
An ACGME task force subsequently softened the restrictions, limiting the 16-hour rule to interns. A public comment period for those guidelines just ended, but most medical centers are already assuming that they will be put in place next summer unchanged and are planning accordingly. I spoke to two University of Chicago Medical Center faculty members who supervise residency programs – Terrance Peabody, chair of orthopedic surgery, and Vineet Arora, associate professor of medicine – about how hospitals are preparing for the changes.
How do you feel about the new ACGME recommendations?
“The real issue is that, in surgery culture, taking care of someone for 24 hours is a big part of the learning experience,” Peabody said. “It’s important that residents undergo following somebody through that period of time. The concept of making a surgeon a shift worker goes against the real culture of surgeons, who feel obligated to provide some continuity of care, and whose tasks aren’t easily delegated the way they are in internal medicine.”
“I think it’s a very tall order for medicine especially given the value of following patients through the night,” Arora said. “I can also understand it’s a reasonable compromise between what ACGME had to balance, which was the fact that there was a public pressure to reduce hours amid the data about fatigue, as well as still preserving the opportunity for residents to work overnight and follow patients.”
How will the restrictions change residency?
“In essence, it turns residency on its head,” Arora said. “We used to have our inexperienced interns in the hospital and staying overnight, and these recommendations focus a lot more on supervision and having a very controlled environment for the intern to practice with less fatigue.”
“Interns are now sort of like 5th year medical students,” Peabody said. “And while numbers have stayed stable since the 2003 changes as far as operative cases, that means surgical residents are not in the clinic as often. The ultimate hazard is that surgeons will become proceduralists, just doing operations as opposed to saying who should be operated on and when.”
How will academic hospitals be affected by the change?
“Financially, it will be a tremendous burden on academic medical centers,” Peabody said. “Physician extenders typically don’t do surgery, don’t provide surgical care, and they don’t take call at night. And even if they do just inpatient service, it takes three to cover for one resident.”
“I am worried about the money,” Arora said. “We already have had a financial crisis in a lot of hospitals and already responded to 2003 duty hour changes. It took quite some time to comply with those changes, and it takes a lot of money. The timeline for implementation [of the new proposed restrictions] is very fast.”
[Today, the Alliance for Academic Internal Medicine requested that the new restrictions go into effect a year later than planned, in July 2012]
What are the alternatives to further shortening residency hours?
“One possibility is to make the people you have more efficient,” Arora said. “Some of our work has shown that one-third of resident work is uneducational – transporting a patient, filling out forms, and other clerical work. You could imagine making more efficient resident work by removing that uneducational work, since a lot of it could be done by lower cost labor.”
“What ultimately may have to happen is to separate the education component of residency from the service component,” Peabody said. “We may need to finally work out whether they are students or employees. But that would be a paradigm shift.”
Are there ways to change what a resident does over the course of their shift to avoid fatigue?
“If you ask someone, ‘do you want a well rested intern versus a tired intern?’, nobody’s going to pick the tired intern. But if it’s a tired intern who knows you versus a well-rested intern who doesn’t know you, that’s different, and that may vary by clinical context,” Arora said. “If it’s who is going to put in an arterial line, I’d take the most experienced person bar none, and probably well-rested is better, becase it’s a vigilance task. If I was wanting to have an end-of-life discussion or make a decision about a treatment plan based on complex medical problems, I want someone that knows me. It may be by looking closely at the scope of work that residents do we can design safer systems, such that after you’re up for 16 hours you don’t do these vigilance tasks, but sometimes you stay in the hospital to complete a familiarity task.”
What do you think the long-term effect of the changes will be on residents?
“The world hasn’t fallen apart after 2003, but those people have a much different view than faculty or senior colleagues,” Peabody said. “The same thing will happen if the 16-hour rule goes through. You always assume whatever you’re doing is more difficult than what your predecessor did, while your predecessor assumes the current residents’ lives are easier.”
“I do think improvements in resident health are important, which is why we should at least not go back the the old unrestricted system,” Arora said. “We’ve shown that we can improve resident health without hurting patients, and that’s a good thing. We don’t know what the effect of 2010 will be, so now we have to look again.”