Patient care versus education
This is the tug-of-war struggle that residency programs constantly grapple with. Residents work in an apprenticeship model where they are both patient providers and learners. Both are critical in residency training, but they sometimes negatively impact each other. For instance, EM residents hand-off their patients to covering residents while attending their weekly conference classes. In contrast, residents may skip that day’s board teaching rounds to manage an acutely decompensating patient.
In 2003, the Institute of Medicine (IOM) set the 80-hour workweek standard for all residency programs. More recently this year, the IOM proposed additional duty hour restrictions:
- When on call, the maximum on-call period is 30 hours. There also needs to be a 5-hour continuous sleep period during this time such that the resident’s maximum awake period is 16 hours.
- Night float must not exceed four consecutive nights and must be followed by a minimum of 48 continuous off-duty hours after three or four consecutive nights.
- Both internal and external moonlighting should be counted against the 80-hour weekly limit. Currently moonlighting is not counted.
- The maximum in-hospital, on-call frequency should be every third night without averaging. As an intern on the orthopedics team, I remember taking q2 night calls, intermixed with some q4 and q5 night calls so that everyone can get a weekend off. This would be eliminated with this new rule.
- The minimum time off between scheduled shifts should be 10 hours after a day shift, 12 hours after a night shift, and 14 hours after any extended duty period of 30 hours.
- Mandatory time off duty should increase to 5 days off per month: one day off per week, without averaging, and one 48-hour period off per month.
On surface level, the IOM logic makes sense. Give the residents more rest from patient care responsibilities. This will give us better learners.
But let’s look deeper.
Annals of Emerg Medicine opinion article
- When residents graduate and practice as attending physicians, they may be asked to work more consecutive hours or more frequent shifts than they have ever worked during residency. Is this right?
- Having more hours off (eg. 5-hour nap), days off, and work hour restrictions will result in more patient hand-offs, which are known to increase patient care errors. It’s too bad that patients change their clinical course dynamically and don’t follow the work clock.
- Limiting the number of consecutive night shifts will result in more circadian dysrhythmias.
- Every specialty is different in training requirements, learning environments, and patient population. While some specialties (i.e. surgical programs) might benefit from a more structured reduction in work hours, imposing a blanket statement on all programs seems impractical and short-sighted.
- If residents work fewer hours overall, residency programs should be extended by at least another year of training. Experiential learning is critical in preparing a resident for clinical practice as an attending physician. You really never want to hear your doctor saying, “Hmm, I’ve never seen that before.”
- With all the shorter work hours, hospitals will need to hire more attending physicians and mid-level providers to cover the gaps in patient care.
The Residency Review Committee for EM, ACEP, and EMRA have responded with a joint letter applauding the philosophy of optimizing resident learning and patient safety. They, however, opposed the implementation proposal for stricter duty hour rules. I totally agree.
Millard WB. For Whom the Bell Commission Tolls: Unintended Effects of Limiting Residents’ Hours. Ann Emerg Med. Oct 2009; 54(4):A25-A29.