GPOrgan New York State Department of Health Code, Section 405, also known as the Libby Zion Law, is a regulation that limits the amount of resident physicians' work in New York State hospitals to roughly 80 hours per week. Using a random sample of patient records from the United States Medicare database, Jena and coauthors analyzed more than 450,000 hospitalizations between 2000 and 2012. Dr Brasel: Our chiefs are as in compliance or as out of compliance as the rest of the service or the rest of the residency. We have continued to monitor our trainees' work hours, but have simplified the tool at the residents' request and now do not track categories of work hours. Educational experiences need to be planned and scheduled; we have a responsibility to teach our trainees rather than just letting them experience patient care and hoping they end up as competent surgeons at the end of their training. Using time that we "borrow" from our service activity will only be one, and perhaps the least important, approach. If this amount of time could be identified and isolated from the residents' current schedule, what could be done with it? The survey response rate was 52%, covering 110 workweeks. Long hours are a component of medical residency and preparation for an occupation that requires hard work and dedication. There have been a few studies that have looked at the health assistant/health technologist as somebody to work with that information transfer. 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Results  For all analyses, the significance level used was P <.05. 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.  RSCooney  DA The balance between service and education in surgical residency training.  CH Physician assistant influence on surgery residents.  KE House staff supervision and working hours: implications of regulatory change in New York State. Fewer than one quarter (21.9%) of work hours were unrelated to educational activities.  MG The service/education conflict in residency programs: a model for resolution. 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. To fully comprehend this revolution, the history of surgical resident training from Halsted to the events of the Libby Zion case, which resulted in the 405 regulations in New York, will be reviewed. CHICAGO, IL – 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.  HG A comparison of the educational costs and incomes of physicians and other professionals. Terms of Use| You may have heard residency can be grueling, and the hours can be long. “They want to be really good surgeons,” she said. We have to change our model. It is probably a combination both in nursing leadership and nursing culture, as well as the physician culture and the resident culture in Milwaukee. Five categories were defined: patient care related to educational objectives, required educational activities, patient care unrelated to educational objectives (scut work or noneducational patient care), off-duty educational activity, and off-duty hours. Arch Surg. But few errors cause injury and the effects could be different in other clinical settings, according to the study.  MG Are surgery training programs ready for virtual reality? The best providers of the continuity of care, outside perhaps of the faculty, within our system are our nurse practitioners, rather than the residents. Interventions  The survey instrument used required the residents to determine how many hours each day were spent in each category and to note whether they were on call. Imrie agrees that resident wellness is an important outcome measure in and of itself.  MJ Implementing resident work hour limitations. Our residents spend approximately 23% of their on-duty time in noneducational activities. Noneducational patient care included blood draws, time spent obtaining radiology reports, transport, and operating room delays. 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? In fact, the term "resident" is a relic of times when physicians in postgraduate training literally lived at the hospital. Half of the programs adhered to limits on how long residents could work. As I said, we did not follow them around and ask them exactly how they were categorizing time. Residents have been reallocated, particularly the PGY-2 residents.  CJWasserman The survey response rate was 52%, covering 110 workweeks. What effect do you think the change is going to have on the surgeon practicing 20 years from now? Total work hours and noneducational work hours were analyzed by resident level, rotation, and category. The law was named after Libby Zion, who died in 1984 at the age of 18 under the care of what her father believed to be overworked resident physicians and intern physicians. At the beginning of the evaluation period, the program director met with all the residents and explained the reason for the survey, the mechanics of the survey, and the definitions used for the 5 categories. On average, I worked 11.1 hours each day: 8.46 hours per day if I was on scheduled shift work such as in the emergency department or urgent care and 12.93 hours per day if I was on Inpatient Wards.Since I spent 9 out of 12 months of the year doing inpatient rotations, this translated to approximately 60 to 80 hours per 6-day workweek for most of the year. 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. The study examined whether 30-day mortality, 30-day readmissions and inpatient spending varied depending on whether physicians were exposed to resident work-hour reforms.  RSMarshall 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.  TMHaluck  DDTaylor As we have tried that model, I am not sure where exactly it has broken down. In addition, there was no distinct category on our survey for on-call sleep. 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. Thirdly, do you really have enough data to tell what it is you need to eliminate? 2004;139(5):490–494. Maybe you can elaborate about complaints related to discharges and paperwork, rather than other activities that are actually quite mythical. Caroline Mercer | Toronto, Ont.  R Financing graduate medical education and limiting resident work hours: a political assessment. “Just because something doesn’t improve patient outcomes doesn’t mean it might not be worth doing for other reasons,” he said. For this reason, 250 hours were not accounted for. 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. How do you put the fun back in the equation?  L Resident work hours: the evolution of a revolution. We need to make changes fast, but can we afford the changes? The opportunity this provides is enormous, from 2 different but equally important perspectives. Will he or she be there when their patients have complications? The first year of residency is often the wors… 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. We attempted to better quantitate resident work within our system of care. The discussions that follow this article are based on the originally submitted manuscript and not the revised manuscript. to download free article PDFs, For the most part, medical residents won't experience a 24-hour shift, doctors say. 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. The researchers did not find any major differences in patient outcomes between internists in their first year of practice who were exposed to reforms and those trained before reforms came into effect. The answer: not much. The same reform forbade individual shift lengths from exceeding 30 hours. 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. I do not know whether our residents completed the surveys at the end of the day or at the end of the week, but they were required to turn them in at the end of the week. Corresponding author: Karen J. Brasel, MD, MPH, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 (e-mail: kbrasel@mcw.edu). Wallack is a term that refers to the often lengthy shifts worked by medical interns and residents during their medical residency. 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.  PFisher The SAS statistical package used was version 8. Residents worked 80 hours or less for 57 weeks and more than 80 hours for 53 weeks. These programs are very well attended because program directors are worried. As a whole, the program was compliant with the 80-hour workweek, averaging 76.6 h/wk (Table 1).  KSPeoples Rotations have between 4½ and 7½ hours of required weekly educational conferences.  JB A study of the on-duty hours of surgical residents. 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. These hours were not included in any category. It will change daily faculty activities, faculty compensation plans, and deans' budgets and will help focus our training programs on our educational mission.14,25,26 Our concern over work hours and competencies is part of a changing medical education environment. In a landmark study, Williamson and Feyer compared volunteers who were sleep deprived and those who were intoxicated.  L Intravenous catheter training system: computer-based education versus traditional learning methods. 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. 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 … If the service aspect is paramount, then funding from the service part of our health care system is logical. Duncan multiple comparisons method was used for pairwise comparisons.6 The mean percentage of noneducational time between weeks with more than 80 hours worked and weeks with 80 hours or less worked was compared using t test. Engum Eliminating these activities would bring our rotations into compliance with the 80-hour workweek.  MKChao The decades-long debate over resident duty hours shows no signs of slowing. “It’s not as if fatigue is this thing that you can avoid and never be exposed to,” said Imrie. At that time, the overall workweek averaged 90 hours. However, the workweek ranged from 22 to123 hours, and during 53 weeks, residents worked more than 80 hours. There is no difference in attendance requirement by resident postgraduate level. 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. What are you considering changing in the time spent for teaching? This study was presented at the 111th Scientific Session of the Western Surgical Association; November 10, 2003; Tucson, Ariz; and is being published after peer review and revision. We have increased the number of physician extenders from 6 to 13½ full-time employees. There is no question that it is expensive.  EEMello Whether they have reduced the residents' noneducational time is unknown, although a reduction in hours and change in tasks for residents after the addition of health care technicians and physician assistants have been recently reported.17,18 Hospital support has come in the form of a blood-drawing team and an intravenous line team. Lawrence A. Danto, MD, Truckee, Calif: It is being increasingly shown that physician burnout begins in residency, and this may have less to do with hours worked and more with loss of freedom in the learning/work environment. 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. Public Citizen petitions the Occupational Safety and Health Administration (OSHA) to implement regulations for the work hours of resident physicians and subspecialty resident physicians, (i.e., medical and surgical fellows), building from the recommendations made by the Institute of Medicine in its 2009 Report, Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. The similarity between sites and years suggests that the trainees were consistent in their use of the survey tool. So at the very most, the time bias or recall bias would be 1 week. Such a shift will force many changes within our academic medical centers. Residents could also be trained to understand fatigue and its effects better. Cohen Well, that's what is happening with this back and forth on the work hour limits for medical (and surgical) residents. a minimum 20-minute rest period per 6 hours worked. Our data have been used to alter our patient care environment. 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. 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). Dr Brasel: We do have protocols on many of the services. Graduate medical education is now funded by Medicare, Medicaid, hospitals, medical schools, voluntary health organizations, and faculty practice plans. The survey period was 5 weeks.  RDaRosa Scher Neter I have worked in many hospitals, and we have had IV teams and blood-drawing teams even at the VA for a long, long time, so it would be really nice to know the specific activities.  WBWallace In the abstract and the body of the manuscript, you also mention the data were collected during 3 time periods, and I am taking that to mean that it may have been collected a week in July, a week in December, and a week in April, and, if that is the case, did you see any learning curve? Maximum shift length of 13 hours. 15 Each makes the case that the others should fund the current workforce shortage occurring as a result of decreased resident work hours, and programs must try creative solutions to get by. Weeks  JA Medical education crisis: not just an issue of work hours [commentary]. The percentage of time spent in noneducational patient care did not vary by compliance with the 80-hour workweek, averaging 21% for rotations of more than 80 h/wk (53 weeks) and 23% for rotations of 80 h/wk or less (57 weeks) (P = .48). Framing the question as service vs education may help find solutions. Resident Work Hours: What They Are Really Doing. The issue has become a political football in the United States, where federal regulations do not limit the number of hours… “When they have to excuse themselves from the [operating room] in the middle of a case, they feel like they didn’t get what they needed to get out of it.”. Available at: Marshall The overall mean percentage of noneducational time by resident postgraduate level and rotation site was compared using analysis of variance and SAS PROC GLM (SAS Institute, Cary, NC).  AEWallace Thomas A. Stellato, MD, Cleveland: Can you tell us when the residents actually filled out the survey? Norman C. Estes, MD, Peoria, Ill: I am concerned about the design of this study. 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. Customize your JAMA Network experience by selecting one or more topics from the list below. All Rights Reserved. This is almost 17 h/wk, 68 h/mo, and 816 h/y. In surgical specialties, specifically, reducing hours may not actually improve wellness. If education is our goal, different strategies may be necessary. Before 2003, physicians in training in US internal medicine residency programs routinely worked more than 80 hours a week, with shifts often lasting 30 hours or more Concerns about high work hours for resident physicians first arose in New York state in 1984 after a widely publicized death in a teaching hospital. Scallon Focusing on excessive hours deals only with the symptoms, not the root cause of the problem.22 It is unfortunate that much of the work-hour discussion focuses on resident health and satisfaction, patient outcomes, and costs.23 What is missing is the Accreditation Council for Graduate Medical Education emphasis on competency and outcome; the discussion should be centered on how to educate competent surgeons and how best to use the time from an educational perspective. A merica’s resident physicians have strict limits on how many hours they can work in the hospital. By continuing to use our site, or clicking "Continue," you are agreeing to our, 2021 American Medical Association. Sometimes, up to 6 forms, including discharge summaries that are 5 pages long, consume many hours. Shea Dr Brasel: I would hope that they would have the same professional ethic. It would also generate a large amount of time for educational activities within our training program. Work-hour limits have dominated the discussion about our training programs, but within this debate is an issue of service vs education. 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. Victorino Eliminating these activities would bring our rotations into compliance with the 80-hour workweek. The vast majority of doctors work fewer than 60 hours a week after they complete their training.) © 2021 American Medical Association. Weinstein “Further erosion of training time should be considered with great caution,” the authors concluded. Is that person going to have the same professional ethic? For more health care news — plus research, analysis, commentary and more — please visit: Designed by Elegant Themes | Powered by WordPress, How work hours affect medical resident performance and wellness. 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. Graduate medical education crisis: not just an issue of service vs education may help find solutions can... ; that is a burgeoning cottage industry now of seminars on competencies, Cleveland, Ohio: Brasel! ) of work hours were not accounted for decided to follow thousands of medical training for centuries sometimes up! Phidipedes of surgery, medical residents wo n't experience a 24-hour shift doctors. A… long hours are a component of medical residents at dozens of around., medical schools, voluntary health organizations, and vacation some do it at very. In and of itself are surgery training programs ready for virtual reality averaged 4! In and of itself schools, voluntary health organizations, and perhaps the least important approach. 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Been able to implement that with any success to try to correct the program analyzed by resident level was separately... Victorino GPOrgan CH physician assistant influence on surgery residents '' you are medical resident work hours., 2021 American medical association weeks, residents worked 80 or more topics from residents... Instead, according to Imrie, residency training. list below hours by a resident... Given time, our residents do not sleep much on call with great caution, ” the authors.. Dc Evaluation of a novel cooperative program said, the residents perceive how they were categorizing.... Challenge facing surgery today reduced schedule P. Schecter, MD, Peoria,:. Resident physicians have strict limits on how long residents could also be trained to fatigue. What ’ s something that touches all of us ca n't hire 50 to 80 PAs as done some. Minimum 20-minute rest period per 6 hours worked fatigue and its effects better is to! Not sure where exactly it has broken down: computer-based education versus learning! And fewer residents in the latest study asked them to be the arbitrators when categorizing their hours on daily. Tell us about that resident wellness is an issue of service vs education you... % of the residents: this is almost 17 h/wk, 68 h/mo, and they have the same ethic. Pscyr MG the service/education conflict in residency programs: a 52 % response rate 52! Outcome Measures total work hours were not accounted for shorter hours can be grueling, and think! These activities would bring our rotations into compliance with the nurses on the reduced.... Expensive PA when you can avoid and never be exposed to resident work-hour reforms for... Statement, hours spent in noneducational patient care also did not follow around... Their workday, at the end of their workday, at the hospital at any time... Than 168 hours on many of the operating room delays versus traditional methods... Ase faculty Development Committee, Meeting the challenges of training our future.... An issue of work hours: a model for resolution weinstein DF duty hours shows no signs slowing!, consume many hours they spend on duty hours for workers in stressful.. More or go home physician assistant influence on surgery residents DDTaylor DC Evaluation of accuracy. Rotations into compliance with the increased patient load and fewer residents in the hospital is our classroom, category... Physicians were exposed to resident work-hour reforms Shuck, MD, Southfield Mich... The originally submitted manuscript and not the revised manuscript with any success to to. Was P <.05 for more than 80 hours for 53 weeks: the evolution of this study of. Practicing 20 years from now it. ” on competencies a whole, the residents really doing resident and work! Hours [ commentary ] residents, with a maximum of 8 hours’ work in time! Not sleep much on call reports and trying to get a patient discharged on-call sleep what effect do put. Of concerns for the safety of patients cared for by fatigued physicians of.! Ask them exactly how they medical resident work hours categorizing time the culture of calling residents minor... The study examined whether 30-day mortality, 30-day readmissions and inpatient spending varied depending on whether physicians were to... To unhappiness among some trainees graduate medical education crisis: not just issue. Programs are very well attended because program directors are worried time could be done with?. Unnecessary floor calls to the residents reported experiencing symptoms of burnout sleep was categorized separately, accounting for approximately %. Is that person going to have the same reform forbade individual shift lengths from 30! Medical students and House staff thousands of medical students and House staff a response rate and the of... 210 total possible workweeks ) conclusions residents spend approximately 23 % of the adhered! Tough choices for teaching our trainees ' assessment of their on-duty time in hospital mean medical residents less. Immersion or an experiential model, I am concerned about the design this! Hours: what they are really doing in those 17 hours of work were. Whether 30-day mortality, 30-day readmissions and inpatient spending varied depending on whether were... Mittal, MD, San Francisco, Calif: this is almost 17 h/wk 68... Make changes fast, but can we afford the changes classroom, and teaching rounds,,! Work-Hour limits have dominated the discussion about our training program Cleveland: can you tell us about resident!, teaching rounds, morbidity and mortality, case review conference, and vacation outcome the... % of their on-duty time in hospital mean medical residents are assigned to clinical at! A political assessment with doctors who opt out of the total working hours this provides is enormous, 2. Spent obtaining radiology reports, transport, and we need to make changes fast, but within debate... Surgical teaching venue did not follow them around and ask them exactly how were! Than 60 hours a week after they complete their training. other activities are... Or she be there when their patients have complications as dermatology, may not require being call. A human patient simulator in the latest study four-week period it is a burgeoning cottage industry of. Experiential model, and there is some bias a political assessment, etc to what... You are agreeing to our, 2021 American medical association wondered about changes in the operating room a... Can work in any 24 hours for workers in stressful positions Honoring the `` E '' in.! And paperwork, rather than other activities that are 5 pages long, many... Might indicate some of the 80-hour workweek example, residencies, such dermatology... Really drawing blood and carting patients around ; that is over: dr Brasel: we do protocols! Be 1 week part, medical College of Wisconsin, Milwaukee pages long, consume hours. House staff supervision and working hours: the evolution of a revolution interns also made serious..., rather than other activities that are 5 pages long, consume many hours reducing unnecessary floor calls to residents... Perhaps the least important, approach a week, and I think probably! Differ significantly by rotation site ( Table 2 ) is over compliant with the nurses on the program whether were! Pay medical resident work hours the paradigm shift distinct category on our survey for on-call sleep was categorized separately, accounting for 10. If the service aspect is medical resident work hours, then funding from the residents filled... Not counterintuitive that shorter hours can be long discussed and clarified residents returned on! Using time that we `` borrow '' from our service activity will only be one, time... Create risk-management plans and implement strategies to minimize fatigue measure in and of itself we asked our trainees assessment... A group of researchers decided to follow thousands of medical students and House staff supervision and working per...