AAMC Reporter: July 2007

Five Years Later, Resident Hours Limits Still Debated

The quality of resident education is still at issue in the resident duty hour discussion.

July 1, the first day of residency training for new medical school graduates, marked the five-year anniversary of the Accreditation Council for Graduate Medical Education's (ACGME) watershed decision to limit resident duty hours to 80 per week.

Announced by the ACGME in June 2002, the policy took effect the following July. In addition to the regulation including the 80-hour workweek, residents received one day off per week, a 10-hour break between shifts, and the "24 plus six-hour" rule for continuous on-site duty, which limited clinical time to 24 consecutive hours, with six additional hours slotted for transfer of patient care and participation in didactic activities such as lectures. The regulations were intended to improve patient care, resident well-being, and the educational environment.

In the intervening years, many people have tried to gauge the regulations' success through studies, discussions, and informal anecdotes. So far, there seems to be little consensus.

Some insist the rules have unequivocally improved resident quality of life.

"There is no doubt that residents are happier. They will tell you that their lives are better," said Timothy C. Flynn, M.D., associate dean of graduate medical education (GME) at the University of Florida College of Medicine and a member of the initial ACGME committee that recommended the duty hour limits.

Robert O. Carpenter, M.D., M.P.H., a surgical resident at Vanderbilt University School of Medicine and a duty hours study investigator who examines residents' compliance with the regulation, is not so sure.

"OB/GYN and surgical residents have not shown significant improvements in quality of life," he said. "There is a great deal of concern from these residents that they may not be getting the same quality of education [as before]."

Extra time away from the hospital is a mixed blessing, Carpenter added.

"Residents are happy to sleep and spend time with their families, [but] are very worried about their patients."

Kelli J. Harding, M.D., chair-elect of the AAMC's Organization of Resident Representatives, said residents probably appreciate more free time, assuming programs apply these regulations fairly.

"As long as we are providing the best care possible for our patients, we shouldn't be made to feel guilty for having a life outside the hospital," said Harding, a psychiatry clinical research fellow at Columbia University College of Physicians and Surgeons.

To date, the notion of whether the regulations are paying real dividends—be it through patient care, decreased resident fatigue, or other metrics—is similarly inconclusive.

"In a few cases that have been looked at, there have been fewer resident errors. Intuitively, it means that there should be better patient care and safety," said Rosemarie L. Fisher, M.D., associate dean of graduate medical education at Yale University School of Medicine and head of the ACGME internal medicine review committee.

One common area of risk for potential errors are "handoffs," when the physician treating a particular patient passes on this responsibility to another doctor once he or she has reached the duty hour limit.

"Any time you have any form of a hand-off there is truly a risk of the ball being dropped and information not being passed on," Carpenter said.

Recognizing this risk, hospital clinical leaders, residency program directors, and others, are currently developing ways to minimize the negative impact of hand-offs.

As for resident fatigue, a study published in the June 2007 issue of the journal Academic Medicine reported that burnout was common among otolaryngology residents, with residents indicating duty hours as the strongest factor. Moderate burnout was evident in 76 percent of residents, with high and low burnout reported at 10 percent and 14 percent, respectively. One problem that is still emerging is the economic impact of the ACGME's policy. To compensate for the loss of physician hours, institutions have had to find alternate personnel solutions.

Franklin J. Medio, Ph.D., associate dean of graduate medical education at the Medical University of South Carolina, said the regulations have cost the university upwards of $7 million in extra personnel costs. Resident noncompliance is another concern. Potential reasons include pressure from program directors, attending physicians, and administrators, said Carpenter.

Residents' concern for their education, their patients, and their reputations are internal forces that also weigh in. Carpenter explained that residents tend to underreport these extra hours because they fear losing their program if violations are discovered.

A better understanding of the regulations' impact may take much longer than five years. But if the current thinking is any indication, the medical community will have plenty of time to sort it out.

"[We] are at the end of an era," Fisher said. "The duty hours are here to stay. Period."

—By Elissa Fuchs

Burnout in Residents of Otolaryngology-Head and Neck Surgery—Academic Medicine, June 2007

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