Perceived impact of duty hours regulations: a survey of residents and program directors

Do regulated resident working hours affect medical graduate education? Trends in the American psychiatry board pass rates pre- and post-2003 duty hours regulations

Aims and method To assess trends of the American Board of Psychiatry and Neurology examination pass rates before and after the 2003 duty hours regulations (DHR). We obtained the pass rates for part I and II for years 2000-2010. Data were divided pre-DHR (2000-2003) and post-DHR (2007-2010). Results During the pre-DHR period, first- and multiple-attempt group pass rates were 80.7% and 39.0% which changed in the post-DHR period to 89.7% and 39.1% respectively. Similarly for the part II exam, the pre-DHR first- and multiple-attempt group pass rates were 60.2% and 43.5% respectively, which increased to 78.7% and 53.8%, among the post-DHR group. Overall, there was a significant increase in the first-attempt candidates pass rates for parts I and II, whereas multiple-attempt candidates did not benefit as strongly. Clinical implications The results suggest that the 2003 DHR may have had a positive impact on examination-based medical knowledge in psychiatry.

Otolaryngology Resident Workflow

Objective. To investigate workflow in an otolaryngology–head and neck surgery residency program over 1 year and identify areas for improvement in the efficiency of resident education and training.

Study Design. Time-motion study.

Setting. An urban, county hospital and a Veterans Affairs medical center hospital.

Subjects and Methods. Eight otolaryngology residents (4 residents at postgraduate year [PGY] 2 and 4 at PGY 4) were studied using direct observations early and late in the 2008-2009 academic year. Resident activities were categorized, and a database program was generated for a handheld computer to facilitate time entry. Resident activities were classified into a taxonomy of tasks and their educational value was assessed. For each PGY level studied, observations were made for clinic and operative days.

Results. Residents spent their day on direct patient care (43.5%), indirect patient care (33.7%), didactic education (9.6%), personal activities (7.5%), and transit (5.8%), with activities of marginal educational value consuming 16% of their time. Major inefficiencies included managing administrative tasks, scheduling, and technical difficulties. On average, residents devoted significantly more time to marginal tasks on clinic days (19%) than on operative days (12%; P < .001). These data were compared with previously published data obtained during the pre–Accreditation Council for Graduate Medical Education (ACGME) duty hour mandates era.

Conclusion. This study evaluates resident workflow and efficiency over the course of a PGY in an ACGME-accredited otolaryngology residency program. By understanding the time motion of residents, interruptions and inefficiencies in workflow can be identified to direct future changes to enhance resident education and training in the era of the ACGME duty hours mandate.

Sleep deprivation, physician performance, and patient safety

Long work hours, overnight call duty, and rotating shifts are implicit features of hospital medical practice. Rigorous schedules have been deemed necessary to fulfill the professional obligation of patient beneficence, to optimize trainee learning, and to respond to economic realities. However, the resultant disruption and restriction of physicians' sleep produce demonstrable neurobehavioral impairments that may threaten other fundamental professional mandates, such as that of primum non nocere ("first, do no harm"). This article provides a basic overview of sleep/wake regulatory processes, examines the impact of physician schedules on sleep/wake homeostasis, summarizes the laboratory-demonstrated effects of sleep loss on humans, highlights recent literature on the personal and professional effects of sleep loss on physicians, and, finally, discusses the specific countermeasure of work-hour limits applicable to resident physicians but not attending physicians.

Four years of accreditation council of graduate medical education duty hour regulations: have they made a difference?

OBJECTIVES/HYPOTHESIS

Measure compliance with the Accreditation Council of Graduate Medical Education (ACGME) residents' work hour regulations and evaluate their impact on patient care and residents' performance on the Otolaryngology Training Examination (OTE).

STUDY DESIGN

Retrospective review of an otolaryngology residency program's resident duty hours violations and OTE scores, and review of the associated hospital's benchmark patient data.

METHODS

Residents' duty hour violations were compiled and analyzed for individual violation, postgraduate year (PGY), and service in the program. Annual OTE scores and the department's hospital benchmark measures (inpatient mortality, inpatient length of stay, 30-day readmission rate) were compared before and after the institution of the ACGME duty hours mandate.

RESULTS

The 10-hour rule was most frequently violated; residents on the oncology service and PGY-2 year were most commonly in violation. There was no difference before and after institution of the ACGME duty hours mandate in 30-day hospital readmission rates (P = .42), hospital mortality index (P = .55), length of stay (P = .55), OTE scores (P = .11, Student's t test), and graduating resident's operative volume.

CONCLUSIONS

Institution of the ACGME duty hour regulations did not improve patient care as measured by the 30-day readmission rate, inhospital mortality, and patient's length of stay. Residents' performance on the OTE did not change after implementation of the ACGME rules. Further studies are warranted to assess the impact of the ACGME work hour regulations on patient care and resident-physicians' training.

Perspective: creating an ethical workplace: reverberations of resident work hours reform

Medical professionals are a community of highly educated individuals with a commitment to a core set of ideals and principles. This community provides both technical and ethical socialization. The development of ethical physicians is highly linked to experiences in the training period. Moral traits are situation-sensitive psychological and behavioral dispositions. The consequence of long duty hours on the moral development of physicians is less understood. The clinical environment of medical training programs can be so intense as to lead to conditions that may actually deprofessionalize trainees. The dynamic relationship between individual character traits and the situational dependence of their expression suggests that a systems approach will help promote and nurture moral development. Ethical behavior can be supported by systems that make it more difficult to veer from the ideal. Work hours limits are a structural change that will help preserve public safety by preventing physicians from taking the moral shortcuts that can occur with increasing work and time pressures. Work hours rules are beneficial but insufficient to optimize an ethical work and training environment. Additional measures need to be put in place to ensure that ethical tensions are not created between the patient's well-being and the resident's adherence to work hours rules. The ethical ideals of physician autonomy, selflessness, and accountability to the patient must be protected through the judicious and flexible use of work hours limits, physician extenders, census caps, nonteaching services, and high-quality handoffs.

Restriction of duty hours for residents in internal medicine: a question of quality of life but what about education and patient safety?

Like in other medical specialities, training in internal medicine is confronted with the duty hours regulation. A reduction to a maximum of 48 duty hours has been introduced in Belgium in 1999 for all residents and is still under debate in the European Communities. A reduction of duty hours to a maximum of 80 hours per week was recently adopted in the USA. Several surveys were conducted in this country before and after the introduction of the new system to evaluate its impact on training and patient care. A reduction of duty hours appears to improve the mental health and the security and the quality of life of the trainees. On the other hand, it is suspected that reducing training hours can have a negative effect not only on education but also on patient safety and satisfaction giving the fragmentation of care. This appears to be a key problem, particularly in internal medicine, as it implies more frequent transfers of medical information, a source of medical errors and a loss of responsibility.

Non-housestaff medicine services in academic centers: models and challenges

Non-housestaff medicine services are growing rapidly in academic medical centers (AMCs), partly driven by efforts to comply with resident duty hour restrictions. Hospitalists have emerged as a solution to providing these services given their commitment to delivering efficient and high-quality care and the field's rapid growth. However, limited evidence is available on designing these services, including the similarities and differences of existing ones. We describe non-housestaff medicine services at 5 AMCs in order to share our experiences and outline important considerations in service development. We discuss common challenges in building and sustaining these models along with local institutional factors that affect decision making. Keys to success include ensuring an equitable system for scheduling and staffing, fostering opportunities for scholarly activities and academic promotion (defining the "academic hospitalist"), and providing compensation that supports recruitment and retention of hospitalists. With further work hour restrictions expected in the future and increased requests for surgical comanagement, the relationship between AMCs and hospitalists will continue to evolve. To succeed in developing hospitalist faculty who follow long careers in hospital medicine, academic leadership must carefully plan for and evaluate the methods of providing these clinical services while expanding on our academic mission.