Residents Jeffrey Schreiber, left, and Chris Sonnenday must adapt to ever-changing schedules and less time with patients.

In the years to come, there will doubtless be a special place in medical history for the "in-between" residents, for those who experienced both the final days of the century-old tradition of working grueling 36-hour shifts and the beginning of the modern era of 80-hour workweeks.

Chris Sonnenday, a fourth-year resident in general surgery, will be among those telling war stories. He finished the first three years of his residency in 2000, followed up with a three-year research fellowship, and exchanged his lab coat for green scrubs again on July 1.

"I left a very different residency than the one I came back to," says Sonnenday. "You might expect that, as residents, we'd stand up and rejoice that these regulations have been passed. But I'll tell you, if you're the chief resident on the GI service and a case comes up that you may have one or two opportunities during your entire residency to do … well, many of us have to be dragged kicking and screaming out of the hospital."
During the past decade, American medicine has had to withstand any number of shake-ups-from the managed care revolution, to a decline in reimbursements, to the tightening of rules on patient privacy and clinical trials. Now it has to overhaul the period called residency, the apprenticeship that turns a medical school graduate into a board-certified physician.

New rules, in general, say that residents are limited to working 80 hours a week, in some cases averaged over four weeks, and can work for no more than 24 hours at a stretch. They are to be on-call no more than every third night, must have 10 hours off between shifts and one day in seven free of all duties. The standards are set by the Accreditation Council for Graduate Medical Education (ACGME).

Now, as the Department of Medicine's Internal Medicine residency program works to accommodate ACGME requirements (see sidebar, below), many young doctors-in-training in Hopkins' 74 other programs wonder whether the requirements will compromise their experience and the intensity of their training. And the people in charge of medical education throughout the nation's 7,800 residency programs have found it isn't easy to restructure the old system, which sometimes meant working 120 hours a week (out of a possible 168) and was deemed a rite of passage for physicians for more than 100 years.

"Like my peers, I worked 36 hours every third night for years," says Jessica Bienstock, director of the Gyn/Ob residency program at Hopkins Hospital and Bayview Medical Center. "But did it make me a better doctor? I'm not sure."

Bienstock can remember times during her internship at Manhattan's Beth Israel Medical Center when her fatigue made her actually resent the prospect of another delivery. Because of that experience, she began addressing the needs of her trainees long before there was even a rumor of new standards. When a resident had a wreck on the way home after a long shift, the department arranged for a taxi service to take house staff home, no matter where they lived. She put into place an 80-hour schedule more than a year before it was mandated by the ACGME.

Gyn residents themselves have helped set up the new system of night floats-in essence, working for just 12 hours at a time-and have identified problems and come up with creative solutions. When second-year residents were found to be working too many hours, for instance, the department hired a nurse midwife. "We've had meetings all through last year looking at scheduling, attitudes, how are people taking this or that," says Kim Fortner, senior resident in Gyn/Ob. "We've changed practically every rotation, and our department has been wonderfully supportive and innovative."

The Department of Surgery, another traditionally tough residency, also has been gradually making changes leading up to the 80-hour week. Like Gyn/Ob, the department hired physician assistants and nurse practitioners to fill in the gaps left by house staff, but opted to organize its schedule around "cross coverage" rather than night floats (the approach adopted by Bayview Medical Center's residents in surgery). "Now, the junior resident on the vascular service, say, covers for the trauma service, and you only spend every fourth or fifth night on call," explains Sonnenday. "It works at Hopkins because there's so much backup available-senior residents, chief residents, attendings."

Because the physicians are now with patients for a much shorter time, signing out for the night has become a concern for residents of all kinds. "You have to leave very clear instructions-who to contact for help, who's to be followed up on-because you inherit patients you didn't examine and work up," says Sonnenday.

He is hardly alone in missing out on the closeness with patients that was inevitable under the old system. "Yes, it's hard to manage a life when you're in the hospital every other night. I totaled my car as an intern. But I'll also tell you it was the best experience of my life and no one knew my patients better than I did." Surgery training programs, Sonnenday says, now are in a state of flux, but he is confident that in time, the right balance will be struck. "The thing I love about Hopkins is that it will rise to the top and figure out a way to solve the problem without compromising patient care and medical education."

-Mary Ellen Miller

 

Internal Medicine In late July, the Accreditation Council for Graduate Medical Education (ACGME), the private group that certifies all medical residency programs in the country, made a site visit at Hopkins Hospital to investigate a complaint alleging violations of duty-hour rules. It found work-hour violations and said that the Internal Medicine training program would lose its accreditation effective June 30, 2004. Although Hopkins had implemented many changes to comply with the work hours rules well before July, since then, Hopkins has redoubled its efforts to ensure that not only Internal Medicine, but all 75 of its residency programs comply fully with new duty-hour and education requirements. (The entire institution will undergo an accreditation review in April 2004, and each program is reviewed separately every few years.) Steps taken include: Hopkins has asked the ACGME to reconsider its decision to decertify the Department of Medicine’s prestigious Internal Medicine residency program and is pressing for full certification. The program has enjoyed full accreditation since 1955. Hopkins has been able to provide documentation supporting its position that despite the very few violations affecting a minor percentage of its residents, it has been in substantial compliance with duty hour rules and outlining steps taken to ensure compliance with the new regulations. An independent team of auditors brought in to review the current Internal Medicine program found it in compliance with ACGME duty hours rules. Throughout the institution, more staff will be allocated to monitor duty hours. A compliance officer has been identified and a team appointed to verify information provided by each residency program on an ongoing basis. The Graduate Medical Education Committee is being reorganized and expanded in order to assure compliance with ACGME regulations. —ABS