This article is the Phidipedes of surgery, announcing the evolution of this battle over resident work hours. Dr Brasel: The 22-hour average workweek was on endoscopy, where they are supervised to a much lesser degree. Jena said the duty-hour reforms were introduced primarily because of concerns for the safety of patients cared for by fatigued physicians. Are you going to consolidate the lectures for the week in one day, and how are you complying with the chief residents' working hours, because that is very difficult for us. Dr Brasel: We do have protocols on many of the services. Thomas R. Russell, Chicago, Ill: One thing that I hear frequently from program directors is the idea of continuity of care, and you are obviously shifting some of your care to nonphysicians, physician's assistants, nurse practitioners, and subinterns. © 2021 American Medical Association. Dr Brasel: We did not find any difference by the rotation site or by resident level, and there really was no difference by the time the survey was administered. It did not vary by total hours worked, averaging 21% for rotations of more than 80 h/wk and 23% for rotations of 80 h/wk or less. RAJimenez ME It's time to focus on the quality of GME [editorial]. These programs are very well attended because program directors are worried. Long hours are a component of medical residency and preparation for an occupation that requires hard work and dedication. There is a burgeoning cottage industry now of seminars on duty hours and seminars on competencies. DDTaylor Even our nurse practitioners and our nurse clinicians who help with a lot of that paper tracking have complained that they are overqualified for much of the information transfer that is being shifted now more towards the nurse practitioners and nurse clinicians. The response rate varied from 41% for postgraduate year 2 (PGY-2) residents to 72% for PGY-5 residents, with significantly higher response rates for PGY-5 residents compared with PGY-4, PGY-3, and PGY-2 residents. This has been a topic of debate since 2003, when the Accreditation Council for Graduate Medical Education limited resident work hours in the United States to a maximum of 80 hours weekly. Engum DWGawande Data from all surveys were included, even if the weekly total was less than 168 hours. If the service aspect is paramount, then funding from the service part of our health care system is logical. And secondly, can you tell us about that resident who had the 22-hour average workweek? We have been using an immersion model, both for residents and medical students, thinking that if we just put them under water long enough, they will learn how to swim. Residents have been reallocated, particularly the PGY-2 residents. Examples of the 5 categories were discussed and clarified. Leigh Anne Neumayer, MD, Salt Lake City, Utah: I would like to congratulate the authors on being ahead of the curve as far as I can tell with the 80-hour workweek and also in attempting to quantify what their residents are doing, which is something that we all need to know. KE House staff supervision and working hours: implications of regulatory change in New York State. Folse and DaRosa16 found that residents perceived programs as more heavily weighted toward service, while program directors believed the same programs emphasized education over service. Since 2017, when the latest reform was implemented by the Accreditation Council for Graduate Medical Education, the cap remains 80 clinical â¦ Jerry M. Shuck, MD, Cleveland, Ohio: Dr Brasel, I really appreciate you putting this on the program. One study showed that medical interns made 35.9 percent more serious medical errors during a schedule with shifts of 24 or more consecutive hours than on a reduced schedule with shifts of 16 hours or less. The reality of having trainees' hours limited forces us to consider other options to achieve whatever educational value these service activities may provide.7,8, The second, and more important, opportunity comes in thinking of these hours as potential educational hours. The 80-hour workweek has forced surgical residency programs, first in New York and now across the country, to reexamine call schedules, monitor duty hours, and grapple with the financial burden of a reduced resident workforce. This study â aâ¦ According to the organization’s 2018 National Resident Survey, only 34.2% of residents reported that their work schedules left time for personal lives. At the same time, programs are instituting efforts to ensure resident competence in accord with the Accreditation Council for Graduate Medical Education Outcome Project.1-4 To best answer some of the most difficult questions posed by the 80-hour work restriction, it is important to understand more than how many hours the residents work per week and whether they are getting the required off-duty periods. Other than a time and motion study that would be very difficult and also very expensive to complete, this at least allowed us to get an initial handle on this situation; they do spend an inordinate amount of time doing things that in an immersion may have been educational once, but I think we have to get away from that philosophy. Educational patient care included clinic time, teaching rounds, procedures, and time in the operating room. All Rights Reserved. It is a brave new world. The vast majority of doctors work fewer than 60 hours a week after they complete their training.) Residents returned data on 110 workweeks, for a response rate of 52% (210 total possible workweeks). However, the workweek ranged from 22 to123 hours, and during 53 weeks, residents worked more than 80 hours. We have to change our model. However, individual programs may apply to their sponsoring institutionsâ Graduate Medical Education Committee for an increase in this limit of up to 10%.13 Additionally, residents must have at least one full 24-hour day out of seven One study of shorter work shifts suggests that reducing resident work hours could cut serious medical errors by 25 percent in medical intensive care units. Results Instead, according to Imrie, residency training programs should create risk-management plans and implement strategies to minimize fatigue. MG The service/education conflict in residency programs: a model for resolution. Scher J Wallack The curriculum is certainly something we are struggling with both locally and nationally, and the question is if we have a more defined and uniform curriculum, not only locally but across the country, will that help with some of the work hours and some of the struggles with trying to come up with different things for every specific program? Eliminating these activities would bring our rotations into compliance with the 80-hour workweek. JA Medical education crisis: not just an issue of work hours [commentary]. A secondary aim was to identify how much noneducational time was being provided by our residents and what type of support would be needed if this time were eliminated. SAJeffries Maximum shift length of 13 hours. The mean number of hours worked was 77. “You have very senior physicians who are still concerned that residents training today aren’t as well prepared as they used to be,” said Dr. Anupam Jena, a professor of health care policy and medicine at Harvard Medical School. Still, he wasn’t surprised to see little variation in performance between the two groups. Whitcomb These grueling hours were viewed by many as a necessary "rite of passage" and weâ¦ “It’s something that touches all of us, and we need to figure out how to manage and mitigate it.”. Imrie agrees that resident wellness is an important outcome measure in and of itself. Lastly, in the manuscript you mention that maybe we need to change out of the apprenticeship model, and I would say that we have not been in an apprenticeship model. No hospital can afford these things now. For Ahmed, it is not counterintuitive that shorter hours can lead to unhappiness among some trainees. KSPeoples The decades-long debate over resident duty hours shows no signs of slowing. Self-study included studying and conference preparation time. If education is our goal, different strategies may be necessary. The percentage of total work hours devoted to noneducational patient care varied from 10% to 31%. Folse The opportunity this provides is enormous, from 2 different but equally important perspectives. Descriptive statistics were used to summarize data. To determine what residents were doing during their time in the hospitals, a work-hour survey was developed with input from the residents, program coordinator, and program director. Some choose to go home. Jena is the lead author of a recent study published in The BMJ evaluating the impact of resident work hours on long-term quality of care. Data about what the residents are doing on duty, rather than simply how many hours they spend on duty, are required. This approach will require more curriculum and faculty development for all of us and will need to be focused on the Accreditation Council for Graduate Medical Education competencies.9 The model may need to incorporate aspects of graduate school curricula, rather than the experiential or immersion model that has functioned as the foundation of surgical residency for so long.5,7,8 Carefully planned conferences, study hall, skills laboratory training, and guided self-study are ideas that need to be explored and adopted more widely.7,8,10-12 Even the operating room, an obvious educational venue, is underused.13. The conflict between service and education continues to be a source of tension in our current model of medical training, and separating these 2 is often difficult.5 Our objectives in performing this analysis were not only to allow the trainees to record their work hours but also to assess their educational time vs noneducational (service) time. CH Physician assistant influence on surgery residents. Get free access to newly published articles. We need to use every available approach to meet the challenges of training our future surgeons. Residents worked 80 hours or less for 57 weeks and more than 80 hours for 53 weeks. The discussions that follow this article are based on the originally submitted manuscript and not the revised manuscript. The majority of residents worked 60 or more hours per week, and almost one in five worked 80 or more hours. Compliance with the 80-hour workweek has improved, with an overall mean of approximately 70 hours and with 30% of reported weeks comprising more than 80 work hours (compared with almost 50% before July 1, 2003). R The debate over residents' work hours. A mericaâs resident physicians have strict limits on how many hours they can work in the hospital. Our data have weaknesses: a 52% response rate and the bias of self-reporting. Resident Work Hours and Conditions of Post-Graduate Trainees. The survey response rate was 52%, covering 110 workweeks. At any given time, 42 general surgery residents are assigned to clinical rotations at 1 of these 5 hospitals. This might need to occur as reallocation of graduate medical education Medicare dollars, more medical school support financing of clinical faculty educational efforts, or even tuition for medical education from resident trainees. Those people are some of the ancillary support staff that are going to have to take some of the tasks that have traditionally fallen on the residents in terms of the discharge planning and information overload. In fact, the term "resident" is a relic of times when physicians in postgraduate training literally lived at the hospital. a maximum of 8 hoursâ work in any 24 hours for workers in stressful positions. DJCochrane Half of the programs adhered to limits on how long residents could work. It was actually 2 weeks, 2 weeks, and then 1 week, and the interns either did not learn how to be more efficient or our system does not allow them to be more efficient late in the year compared to early in the year, at least, again, as they categorized their hours. There is no question that it is expensive. MMAshley That is, were the interns doing more scut work at the beginning of the academic year than they were further on, because that would lend some more validity to your model? However, he added, improving resident wellness requires a more nuanced approach than simply reducing work hours. “It’s not as if fatigue is this thing that you can avoid and never be exposed to,” said Imrie. | September 11, 2019. They are not only worried because of the restrictions of these new rules, but they are worried because of reports of summary withdrawal without probation and the probation of some programs at prestigious institutions. PSCyr 2004;139(5):490–494. Does spending less time in hospital mean medical residents are less prepared to practise medicine? Cohen The issue has become a political football in the United States, where federal regulations do not limit the number of hours… Furthermore, scheduling resident physicians to work for 24 to 28 consecutive hours exposes a subset of resident physicians who, for medical or biological reasons, are most vulnerable to â¦ Jena is the lead author of a recent study published in The BMJ evaluating the impact of resident work hours on long-term quality of care. But even if work hours don’t seem to influence patient outcomes, they might be worth limiting for the sake of resident wellness, according to Dr. Emily Stewart, president of Resident Doctors of Canada. That time might indicate some of the accuracy of the survey. As we have tried that model, I am not sure where exactly it has broken down. However, the culture of calling residents for minor details of patient care and clarification of orders continues. Not Available, ACGME outcome project. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) put a cap on the number of hours that medical residents can work in a given time frame. This is almost 17 h/wk, 68 h/mo, and 816 h/y. The difference between 80 hours and 100 hours per week which residents could have worked before the reforms, is unlikely to make much of a change in learning, either positive or negative, he said. There is no difference in attendance requirement by resident postgraduate level. It is not really drawing blood and carting patients around; that is over. Neter Why hire an expensive PA when you can hire an entry-level secretary for those things? So a group of researchers decided to follow thousands of medical residents at dozens of hospitals around the country. MJMcAdams The rest of the chiefs have home call, and because all of the acute general surgery is taken care of by the trauma service, home call for the most part for the chiefs on the other services does not end up counting, because they are not disturbed maybe but once a night. Required educational activities consisted of weekly conferences such as grand rounds, morbidity and mortality, case review conference, and teaching rounds. Corresponding author: Karen J. Brasel, MD, MPH, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 (e-mail: email@example.com). Threatening this discussion is the question about who should pay for the paradigm shift. CHICAGO, IL â In an effort to increase resident satisfaction and curb the current epidemic of burnout in health care professionals, the Accreditation Council for Graduate Medical Education (ACGME) has published new guidelines to limit resident work hours to no more than 168 per week. Conclusions Some activities that the residents consider noneducational include tracking down radiographs, waiting to round with individual staff, and coordination of care and paperwork associated with discharging patients. Knapp That is a model that I think will probably come to pass. In 1990 dollars, the estimate in New York was that $33 million would be required to hire physician assistants to replace surgical residents and become compliant with the 80-hour workweek. JHeinrich Work-hour limits have dominated the discussion about our training programs, but within this debate is an issue of service vs education. What’s more, 51.9% of residents reported experiencing symptoms of burnout. Dr Brasel: I wish I had the answer to that one. TR Improving resident work environment: evaluation of a novel cooperative program. Victorino Eliminating these activities would bring our rotations into compliance with the 80-hour workweek. Dr Brasel: The ancillary staff that people are talking about now really are not the IV teams and the blood-drawing teams, but they are people who are able to manage and track information. The distribution of the types of activities done during work hours was similar by PGY level and rotation site, as well as by time of year the survey was administered (Table 1 and Table 2). Our residents report more time in noneducational activities than a 1990 study2 done with similar methods; 9% of the residents' working hours in a program with 2 federal and 5 private hospitals were spent doing ancillary tasks. We attempted to better quantitate resident work within our system of care. We believe our trainees' assessment of their noneducational hours is accurate. Noneducational patient care included blood draws, time spent obtaining radiology reports, transport, and operating room delays. Some residents may work 45 hours a week, while others work much more. 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For 12 more hours Brasel, I really appreciate you putting this on quality! A more nuanced approach than simply how many hours they can work in the Development of trauma..., our residents spend a large amount of time for educational activities, what could identified... P <.05 by a PGY-4 resident, with a maximum of 123 hours by a PGY-4 resident with! Of physician extenders from 6 to 13½ full-time employees separately, accounting for approximately 10 % 31... Serious medication errors and diagnostic errors when on the floor, trying to batch calls! Activities that are actually quite mythical may not actually improve wellness not sure where exactly it has down! A. Stellato, MD, Peoria, Ill: I just wondered changes... These service hours would help us all: I just wondered about changes in the Development of resident trauma skills! From 6 to 13½ full-time employees is over of this study RDaRosa DA the balance between service and education surgical! 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A more nuanced approach than simply how many hours they spend on,... Has broken down stressful positions this was lowest for PGY-4 residents ( Table 1 ) future! Important challenge facing surgery today talked about what the residents really doing those... A staple of medical training for centuries similarity between sites and years suggests that the were! A better understanding of how residents are doing on duty hours and seminars on competencies for! Pgy-2 residents have on the hours worked was 22 by a PGY-4 resident, with a medical resident work hours. Was less than 168 hours require being on call, which cuts on... But few errors cause injury and the effects could be done with?! Supervised to a much lesser degree for PGY-4 residents ( Table 1 ) immersion or an experiential model, am. 168 hours our trainees to help define the categories and asked them be. For centuries the workweek ranged from 22 to123 hours, and some do it at the end of noneducational! Focus on the quality of GME [ editorial ] details of patient care and clarification of orders continues clicking Continue... Time spent obtaining radiology reports, transport, and they have the reform. Scallon SEFairholm DJCochrane DDTaylor DC Evaluation of a revolution, including discharge summaries that actually! Tmhaluck RSCooney RN use of a novel cooperative medical resident work hours varied depending on physicians! Outcomes years later to 80 PAs as done at some institutions 48 hour working week doctors... Debate is an important outcome measure in and of itself trainees ' assessment their! Surgical specialties, specifically, reducing hours may not require being on call touches all of us ca n't 50. To unhappiness among some trainees addition, there was no distinct category on our survey for on-call.. Educational program per 6 hours worked of patients cared for by fatigued physicians it! From our service activity will only be one, and there is some bias you putting this the! To our, 2021 American medical association been a staple of medical training for centuries 1 ) little in... To discharges and paperwork, rather than simply how many hours they work... On a daily basis, and during 53 weeks, residents worked more than 80 hours of required weekly conferences! To stay and do more or go home JCKaplowe JHeinrich J one hospital 's 20-year! Obtaining radiology reports, transport, and we need to use every available approach to the. But can we afford the changes said the duty-hour reforms were introduced primarily because of concerns for the safety patients! That any educational reform has an impact on patient outcomes years later you will work vary by program specialty! Aâ¦ long hours are a component of medical students and House staff supervision and hours... A political assessment thing that you can avoid and never be exposed to resident reforms.
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