Perspective: limiting resident work hours is a moral concern

The Association Between Well-Being and Empathy in Medical Residents: A Cross-Sectional Survey

Objective: To evaluate the extent to which personal well-being may be associated with empathy, while controlling for potential confounders. Settings/Location: Residency programs throughout the United States. Subjects: A total of 407 medical residents from residencies including general medicine, surgery, specialized and diagnostic medicine participated in this study. Outcome Measures: Well-being was measured using the modified existential well-being subscale of the spiritual well-being scale. Empathy was measured using the Jefferson Scale of Empathy. Results: Well-being was found to be positively correlated with empathy when adjusted for possible confounders (p < 0.001). In addition to well-being, other factors noted to be statistically significant contributors to higher empathy scores while controlling for the others included age, gender, year in residency, specialty, and work-hours (p < 0.05 for each). After controlling for these factors, a resident's year in residency was not found to be a statistically significant contributor to empathy score. Conclusions: In this study, well-being was associated with empathy in medical and surgical residents. Empathy is a fundamental component of physician competency, and its development is an essential aspect of medical training. These findings suggest that efforts to increase well-being may promote empathy among medical residents.

Work Hours and Cognitive Function: The Multi-Ethnic Study of Atherosclerosis

Background

Cognitive impairment is a public health burden. Our objective was to investigate associations between work hours and cognitive function.

Methods

Multi-Ethnic Study of Atherosclerosis (MESA) participants (n = 2,497; 50.7% men; age range 44–84 years) reported hours per week worked in all jobs in Exams 1 (2000–2002), 2 (2002–2004), 3 (2004–2005), and 5 (2010–2011). Cognitive function was assessed (Exam 5) using the Cognitive Abilities Screening Instrument (version 2), a measure of global cognitive functioning; the Digit Symbol Coding, a measure of processing speed; and the Digit Span test, a measure of attention and working memory. We used a prospective approach and linear regression to assess associations for every 10 hours of work.

Results

Among all participants, associations of hours worked with cognitive function of any type were not statistically significant. In occupation-stratified analyses (interaction p = 0.051), longer work hours were associated with poorer global cognitive function among Sales/Office and blue-collar workers, after adjustment for age, sex, physical activity, body mass index, race/ethnicity, educational level, annual income, history of heart attack, diabetes, apolipoprotein E-epsilon 4 allele (ApoE4) status, birth-place, number of years in the United States, language spoken at MESA Exam 1, and work hours at Exam 5 (β = –0.55, 95% CI = –0.99, –0.09) and (β = –0.80, –1.51, –0.09), respectively. In occupation-stratified analyses (interaction p = 0.040), we also observed an inverse association with processing speed among blue-collar workers (adjusted β = –0.80, –1.52, –0.07). Sex, race/ethnicity, and ApoE4 did not significantly modify associations between work hours and cognitive function.

Conclusion

Weak inverse associations were observed between work hours and cognitive function among Sales/Office and blue-collar workers.

Association of residency work hour reform with long term quality and costs of care of US physicians: observational study

OBJECTIVE

To determine whether 30 day mortality, 30 day readmissions, and inpatient spending vary according to whether physicians were exposed to work hour reforms during their residency.

DESIGN

Retrospective observational study.

SETTING

US Medicare.

PARTICIPANTS

20% random sample (n=485 685) of Medicare beneficiaries aged 65 years or more admitted to hospital and treated by a general internist during 2000-12.

MAIN OUTCOME MEASURES

30 day mortality, 30 day readmissions, and inpatient Medicare Part B spending among patients treated by first year internists who were fully exposed to the 2003 Accreditation Council for Graduate Medical Education (ACGME) work hour reforms during their residency (completed residency after 2006) compared with first year internists with partial or no exposure to reforms (completed residency before 2006). Senior internists not exposed to reforms during their residency served as a control group (10th year internists) for general trends in hospital care: a difference-in-difference analysis.

RESULTS

Exposure of physicians to work hour reforms during their residency was not associated with statistically significant differences in 30 day mortality, 30 day readmissions, or inpatient spending. Among 485 685 hospital admissions, 30 day mortality rates during 2000-06 and 2007-12 for patients of first year internists were 10.6% (12 567 deaths/118 014 hospital admissions) and 9.6% (13 521/140 529), respectively, and for 10th year internists were 11.2% (11 018/98 811) and 10.6% (13 602/128 331), for an adjusted difference-in-difference effect of -0.1 percentage points (95% confidence interval -0.8% to 0.6%, P=0.68). 30 day readmission rates for first year internists during 2000-06 and 2007-12 were 20.4% (24 074/118 014) and 20.4% (28 689/140 529), respectively, and for 10th year internists were 20.1% (19 840/98 811) and 20.5% (26 277/128 331), for an adjusted difference-in-difference effect of 0.1 percentage points (-0.9% to 1.1%, P=0.87). Medicare Part B inpatient spending for first year internists during 2000-06 and 2007-12 was $1161 (£911; €1024) and $1267 per hospital admission, respectively, and for 10th year internists was $1331 and $1599, for an adjusted difference-in-difference effect of -$46 (95% confidence interval -$94 to $2, P=0.06).

CONCLUSIONS

Exposure of internists to work hour reforms during their residency was not associated with post-training differences in patient mortality, readmissions, or costs of care.

Exposing physicians to reduced residency work hours did not adversely affect patient outcomes after residency

In 2003, work hours for physicians-in-training (residents) were capped by regulation at eighty hours per week, leading to the hotly debated but unexplored issue of whether physicians today are less well trained as a result of these work-hour reforms. Using a unique database of nearly all hospitalizations in Florida during 2000-09 that were linked to detailed information on the medical training history of the physician of record for each hospitalization, we studied whether hospital mortality and patients' length-of-stay varied according to the number of years a physician was exposed to the 2003 duty-hour regulations during his or her residency. We examined this database of practicing Florida physicians, using a difference-in-differences analysis that compared trends in outcomes of junior physicians (those with one-year post-residency experience) pre- and post-2003 to a control group of senior physicians (those with ten or more years of post-residency experience) who were not exposed to these reforms during their residency. We found that the duty-hour reforms did not adversely affect hospital mortality and length-of-stay of patients cared for by new attending physicians who were partly or fully exposed to reduced duty hours during their own residency. However, assessment of the impact of the duty-hour reforms on other clinical outcomes is needed.

Use of a Night Float System to Comply With Resident Duty Hours Restrictions: Perceptions of Workplace Changes and Their Effects on Professionalism

PURPOSE

Although some evidence suggests that resident duty hours reforms can lead to shift-worker mentality and loss of patient ownership, other evidence links long hours and fatigue to poor work performance and loss of empathy, suggesting the restrictions could positively affect professionalism. The authors explored perceived impacts of a 16-hour duty restriction, achieved using a night float (NF) system, on the workplace and professionalism.

METHOD

In 2013, the authors conducted semistructured interviews with 18 residents, 9 staff physicians, and 3 residency program directors in the McGill University core internal medicine residency program regarding their perceptions of the program's 12-hour shift-based NF system. Interviews were transcribed and coded for common themes. The authors used a descriptive qualitative methodology.

RESULTS

Participants viewed implementation of the NF system as leading to decreased physical and mental exhaustion, more consistent interaction with patients, and more stable team structure within shifts compared with the previous 24-hour call system. These workplace changes were felt to improve teamwork and patient ownership within shifts, quality of work performed, and empathy. Across shifts, however, more frequent sign-overs, stricter application of shift time boundaries, and loose integration between daytime and NF teams were perceived as leading to emergence of shift-worker mentality around sign-over. Perceptions of optimal patient ownership changed from the traditional single-physician-24/7 model to team-based shared ownership.

CONCLUSIONS

Duty hours restrictions, as exemplified by an NF system, have both positive and negative impacts on professionalism. Interventions and training toward effective team-based care are needed to curb emergence of shift-worker mentality.

Improving Patient Care Through Medical Image Perception Research

The interpretation of medical images across medical specialties is critical to patient care. As technology changes, so does health care, and clinicians today are increasingly viewing medical images in a variety of environments. Although access to such data is useful, even clinicians with expertise in image interpretation make errors. These errors may become more frequent as clinician workdays become longer and the number of images to be interpreted becomes larger. To prevent errors in medical image interpretation, we need to understand the underlying perceptual and cognitive mechanisms that guide image interpretation. We can then use what is learned to develop better training methods, automated image analysis, and processing tools. We can devise methods to reduce clinician fatigue and stress, and develop practice guidelines thereby improving patient care and outcomes.

Duty hour reform in a shifting medical landscape

The circumstances that led to the death of Libby Zion in 1984 prompted national discussions about the impact of resident fatigue on patient outcomes. Nearly 30 years later, national duty hour reforms largely motivated by patient safety concerns have demonstrated a negligible impact of duty hour reductions on patient mortality. We suggest that the lack of an impact of duty hour reforms on patient mortality is due to a different medical landscape today than existed in 1984. Improvements in quality of care made possible by computerized order entry, automated medication checks, inpatient pharmacists, and increased resident supervision have, among other systemic changes, diminished the adverse impact that resident fatigue is able to have on patient outcomes. Given this new medical landscape, advocacy towards current and future duty hour reforms may be best justified by evidence of the impact of duty hour reform on resident wellbeing, education, and burnout.

Medical imaging displays and their use in image interpretation

The adequate and repeatable performance of the image display system is a key element of information technology platforms in a modern radiology department. However, despite the wide availability of high-end computing platforms and advanced color and gray-scale monitors, the quality and properties of the final displayed medical image may often be inadequate for diagnostic purposes if the displays are not configured and maintained properly. In this article-an expanded version of the Radiological Society of North America educational module "Image Display"-the authors discuss fundamentals of image display hardware, quality control and quality assurance processes for optimal image interpretation settings, and parameters of the viewing environment that influence reader performance. Radiologists, medical physicists, and other allied professionals should strive to understand the role of display technology and proper usage for a quality radiology practice. The display settings and display quality control and quality assurance processes described in this article can help ensure high standards of perceived image quality and image interpretation accuracy.

Understanding burnout according to individual differences: ongoing explanatory power evaluation of two models for measuring burnout types

Background

The classic determination of burnout is by means of the dimensions exhaustion, cynicism and inefficacy. A new definition of the syndrome is based on clinical subtypes, consisting of “frenetic” (involved, ambitious, overloaded), “underchallenged” (indifferent, bored, with lack of personal development) and “worn-out” (neglectful, unacknowledged, with little control). The dimensions of overload, lack of development and neglect form a shortened version of this perspective. The aims of this study were to estimate and to compare the explanatory power of both typological models, short and long, with the standard measurement.

Methods

This was a cross-sectional survey with a randomly sample of university employees (n=409). Multivariate linear regression models were constructed between the “Maslach Burnout Inventory General Survey” (MBI-GS) dimensions, as dependent variables, and the “Burnout Clinical Subtype Questionnaire” (BCSQ-36 and BCSQ-12) dimensions, as independent variables.

Results

The BCSQ-36 subscales together explained 53% of ‘exhaustion’ (p<0.001), 59% of ‘cynicism’ (p<0.001) and 37% of ‘efficacy’ (p<0.001), while BCSQ-12 subscales explained 44% of ‘exhaustion’ (p<0.001), 44% of ‘cynicism’ (p<0.001), and 30% of ‘efficacy’ (p<0.001). The difference in the explanatory power of both models was significant for ‘exhaustion’ (p<0.001), and for ‘cynicism’ (p<0.001) and ‘efficacy (p<0.001).

Conclusions

Both BCSQ-36 and BCSQ-12 demonstrate great explanatory power over the standard MBI-GS, while offering a useful characterization of the syndrome for the evaluation and design of interventions tailored to the characteristics of each individual. The BCSQ-36 may be very useful in mental health services, given that it provides a good deal of information, while the BCSQ-12 could be used as a screening measure in primary care consultations owing to its simplicity and functional nature.

The effect of resident physician stress, burnout, and empathy on patient-centered communication during the long-call shift

During the long-call shift medical residents experience a number of stressors that could compromise the quality of care they provide to their patients. The aim of this study was to investigate how perceived stress and burnout affect changes in empathy over the long-call shift and how those changes in empathy are associated with patient-centered communication practices. Residents (n=93) completed self-report measures of stress, burnout, and empathy at the start of their long-call shift and then completed measures of empathy and patient-centered communication at the end of the same shift. There was a significant decline in physician empathy from the beginning to the end of the long-call shift. Perceived stress was significantly associated with higher burnout, which was, in turn, significantly associated with declines in empathy from pre- to posttest. Declines in empathy predicted lower self-reported patient-centered communication during the latter half of the shift. This study suggests that residents who perceive high levels of stress are at risk for burnout and deterioration in empathy toward their patients, both of which may compromise the quality of their interactions with patients.

To leave or to lie? Are concerns about a shift-work mentality and eroding professionalism as a result of duty-hour rules justified?

CONTEXT

Medical educators worry that the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty-hour rules (DHR) have encouraged a "shift work" mentality among residents and eroded their professionalism by forcing them either to abandon patients when they have worked for eighty hours or lie about the number of hours worked. In this qualitative study, we explore how medical and surgical residents perceive and respond to DHR by examining the "local" organizational culture in which their work is embedded.

METHODS

In 2008, we conducted three months of ethnographic observation of internal medicine and general surgery residents as they went about their everyday work in two hospitals affiliated with the same training program, as well as in-depth interviews with seventeen residents. Field notes and interview transcripts were analyzed for perceptions and behaviors in regard to beginning and leaving work, reporting duty hours, and expressing opinions about DHR.

FINDINGS

The respondents did not exhibit a "shift work" mentality in relation to their work. We found that residents: (1) occasionally stay in the hospital in order to complete patient care tasks even when, according to the clock, they are required to leave, because the organizational culture stresses performing work thoroughly, (2) do not blindly embrace noncompliance with DHR but are thoughtful about the tradeoffs inherent in the regulations, and (3) express nuanced and complex reasons for erroneously reporting duty hours, suggesting that reporting hours worked is not a simple issue of lying or truth telling.

CONCLUSIONS

Concerns about DHR and the erosion of resident professionalism resulting from the development of a "shift work" mentality likely have been overstated. Instead, the influence of DHR on professionalism is more complex than the conventional wisdom suggests and requires additional assessment.

US public opinion regarding proposed limits on resident physician work hours

BACKGROUND

In both Europe and the US, resident physician work hour reduction has been a source of controversy within academic medicine. In 2008, the Institute of Medicine (IOM) recommended a reduction in resident physician work hours. We sought to assess the American public perspective on this issue.

METHODS

We conducted a national survey of 1,200 representative members of the public via random digit telephone dialing in order to describe US public opinion on resident physician work hour regulation, particularly with reference to the IOM recommendations.

RESULTS

Respondents estimated that resident physicians currently work 12.9-h shifts (95% CI 12.5 to 13.3 h) and 58.3-h work weeks (95% CI 57.3 to 59.3 h). They believed the maximum shift duration should be 10.9 h (95% CI 10.6 to 11.3 h) and the maximum work week should be 50 h (95% CI 49.4 to 50.8 h), with 1% approving of shifts lasting >24 h (95% CI 0.6% to 2%). A total of 81% (95% CI 79% to 84%) believed reducing resident physician work hours would be very or somewhat effective in reducing medical errors, and 68% (95% CI 65% to 71%) favored the IOM proposal that resident physicians not work more than 16 h over an alternative IOM proposal permitting 30-h shifts with > or =5 h protected sleep time. In all, 81% believed patients should be informed if a treating resident physician had been working for >24 h and 80% (95% CI 78% to 83%) would then want a different doctor.

CONCLUSIONS

The American public overwhelmingly favors discontinuation of the 30-h shifts without protected sleep routinely worked by US resident physicians and strongly supports implementation of restrictions on resident physician work hours that are as strict, or stricter, than those proposed by the IOM. Strong support exists to restrict resident physicians' work to 16 or fewer consecutive hours, similar to current limits in New Zealand, the UK and the rest of Europe.