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an online version of the magazine Winter 2005
Time Clocks in the Trenches
> As medical resident Amar Krishnaswamy, far right, comes to the end of his shift, he signs off his patients to assistant chief of service, Eric Schmick. Listening in is Mavlick Majavdar.
  Today the rules, not the work, dictate when doctors-in-training will leave the hospital. At Johns Hopkins, this new way of working has prompted deep soul-searching..

It is 6 o'clock on a Monday evening. Bonnie Lonze, 30, a surgical intern with a round face and a Ph.D. in neuroscience, climbs the stairs from pediatric surgery to thoracic surgery.

Strain shows in her eyes, but determination drives her step. Lonze meets her fellow intern Alexander Aurora in the thoracic ward. They exchange a few in-jokes, and he gives her a one-page printout on the status of his 22 patients. Then they walk into a narrow room and sit at a counter, shoulder to shoulder, to scrutinize the page. It charts each patient's name, bed location, type and time of surgery, medication, diet, and prognosis. Aurora is signing over their care to Lonze so he can go home for the night, using color codes instead of patient names.

Lonze: “Talk to me.”
Aurora: “Brown is in ICU. Nothing special. Lost two tubes today.”
L: “Good for him.”
A: “Urine output is still low. You can increase his fluids if you have to, but don't overdo it.”
L: “Will do.”
A: “Green is post-op tonight. Nothing special.”
L: “Sweet.”
A: “Red doesn't look good. Going downhill. She's DNR (do not resuscitate), and DNI (do not intubate).
L: “So the plan is do nothing?”
A: “Yes.”
L: “I'll call Dr. Sherwood if she dies.”
A: “Right.”
L: “How about Blue?”
A: “He was in flutter this morning and short of breath, but he's doing well now.”
L: “Sweet.”
A: “He'll be going downstairs with the purple people for a CT scan.”

Their rapid-fire shorthand continues, full of more lingo like the “purple people” reference to the transport team recently hired by the hospital to free interns and residents from non-medical tasks.

The whole sign-off takes less than 15 minutes. Lonze goes back downstairs, while Aurora uses a computer to order tests and update progress notes. He has to get organized, because his wife is scheduled to deliver their baby in two days. While he spends a week on paternity leave, his fellow surgery interns will take in-house call every third day instead of every fourth. The time pressure will be intense.




A revolution is rocking medical education. Residents like Lonze and Aurora, who make thousands of life-or-death decisions about patient care during their training programs, can no longer decide for themselves when they will leave the hospital. Since July 1, 2003, when new rules limiting the work hours of interns and residents took effect, these members of the “house staff” are required to go home when their scheduled time is up. The new rules pose one of the greatest systemic changes to hospital training since the Flexner Report of 1910, which first called for the rigorous resident education programs now in place.

To be specific, the rules say that residents may work no more than 80 hours a week, averaged over four weeks, and no more than 30 hours continuously. Further, they may take in-house call (remain in the hospital) no more than every third night, and they must stop direct patient care after the first 24 hours and devote the remaining six hours to education, paperwork, and preparing for the all-important patient sign-off. They get 10 hours off between work periods and a full 24-hour day off once a week. Programs that break the rules risk losing their accreditation, and residents who graduate from unaccredited programs cannot become board-certified physicians.

Enforced by the Accreditation Council for Graduate Medical Education (ACGME)—a non-profit organization composed of physician, hospital, and university representatives—these work rules were adopted to protect patients, the public and residents themselves. Sleep-deprivation studies have demonstrated time and again that residents who work longer than 24 hours are more likely to exhibit lapses in decision-making and more than twice as likely to crash their cars on the way home. As late as last October, two articles in the New England Journal of Medicine reported a significant increase in medical errors when duty hours are extended and a doubling of attentional failures when residents work a night shift during an 85-hour work week.

Still, at Johns Hopkins—where the national model of traditional residencies was born—giving up the old ways has not been easy. So deeply ingrained is the icon of the “superman” doctor that it has persisted for at least 60 years, sustained by the euphoria new doctors feel as they discover and develop their power to heal.




Richard S. Ross, emeritus dean of the School of Medicine and one of the last generation's leading cardiologists, sits behind his desk in the 1830 Building, dressed in a tweed jacket and a bow tie, and speaks of a time when the house staff lived at the hospital. When he came to Hopkins in 1947, the upper floors of Hopkins' domed main building served as a barracks, divided into suites shared by three or four male residents and interns.

“The married residents, and there were only a few,” says 81-year-old Ross, “did their work and went home. But for the rest of us, the Hospital was home. We never left, except for an occasional movie at the State Theater down Monument Street. A 104-hour work week was common. You had your conscience to contend with if your patient was sick and you weren't at the bedside.”

“I remember how happy I was walking down the hall after midnight, wide awake, with no desire to sleep,” Ross recalls. “What was exciting was the responsibility I felt. I'd meet a patient and say, ‘I'm Dr. Ross'—I had trouble saying that—‘tell me all about it.' I was the patient's friend, advocate, and window on the world.”

Former chair of Surgery John Cameron—who's been at Hopkins since 1958—generally echoes the former dean's sentiments. Still, Cameron managed to surprise a group of residents during Surgery's grand rounds this fall.

After fifth-year residents Brendan Collins and Michael House presented the pros and cons of the new work rules, Cameron, known to be a stalwart traditionalist, announced to the group, “I did it, and I expected everyone else to do it, but my vantage changed when I had a son go into surgery and saw what the demands of long hours did to his family.” He then turned to the two residents and assured them, “I know that you would be just as compulsive and careful in your 100th hour of work as in your first, but your families definitely would suffer.”




Richard S. Ross  
" The hospital was home. We never left, except for an occasional movie. A 104-hour work week was common."
- Former Dean Richard S. Ross, who was an intern in 1947

Ross and Cameron represent two different clinical specialties—Medicine and Surgery—and even when they trained here, their programs took different shapes. In Medicine, residents face enormous responsibility and the need for sophisticated deductive reasoning from the minute they start their internships. Surgical residents move through a hierarchical program that reaches its demanding zenith in the fifth clinical year.

“The judgment surgeons need, especially about whether to operate, develops slowly,” explains Julie Freischlag, head of the Department of Surgery. “The decisions my interns make are relatively basic ones, like which antibiotic to prescribe and whether to open an infected wound. Alex's sign-off sheet was full of information from senior residents, fellows, and attendings. My interns aren't like the interns in Medicine, who admit patients from the emergency room without knowing what's wrong and then have to figure it out. We have very different teaching philosophies.”

Those inherent differences have meant that the new work rules have hit these two departments differently. As interns in Medicine admit patients and learn to make decisions about their treatment, surgical intern Lonze is spending a lot of time in the operating room, because shorter hours mean fewer junior surgeons are available, at any given time to assist. “I've logged over 80 procedures in five months,” she says, but she wishes she could spend more time in the clinic, working up patients and developing her medical judgment.

“Clinics are the best teaching tool we have in Surgery,” says Freischlag. And in fact, the ACGME recommends that each surgical resident at Hopkins spend eight hours per week in a clinic setting. But “we aren't even close to that,” says senior resident Michael Awad, who has taken a leadership role in helping his department adapt to the new work rules.

Awad, who has twice surveyed his fellow surgeons about how they feel the guidelines are working, recently compared the answers he got two and a half years ago with those from this November. The data, he says, show that gradually Surgery is adapting. In the earlier survey, the lengthier a surgeon's experience, the less he or she liked the rules. Senior surgeons worried that shorter hours would compromise patient care and resident education. Younger surgeons mainly looked forward to getting some sleep and living fuller lives.

But the latest results, Awad says, show that older doctors are beginning to see the value of better-rested residents. And while senior residents and attendings still worry about the effect the curtailed schedules are having on patient care and overall training, they rate today's residents the same or better in knowledge, time management, and communication skills than those who trained under the old schedules. And, almost without exception, residents and attendings favor retaining in-house call.

A chief concern, Awad found, is that the rigid rules may breed clock-watchers, that a “shift-work mentality” may take hold and weaken the doctor-patient bond. Critics worry that doctors starting out today are less likely to develop a full sense of responsibility. One long-time surgeon says unequivocally, “There's been a drop in the quality of care, but that's the price you have to pay to get residents out the door.”

Senior residents who took Awad's survey tend to agree. With each additional year of training, residents are more likely to say the new duty hours were having an adverse effect on patient care. They have no doubt that house staff now enjoy a higher quality of life, but worry that patients may be losing.

Attending physicians also appear to be losing. “The blockbuster finding,” Awad says, “is that four out of five attendings said their quality of life has declined. One out of five would not choose surgery again because of the new hours. It used to be the interns who had the worst hours, the worst lives, the most scut, but the work has rolled uphill. Residents used to work 110 hours; now they work 80. Those 30 hours a week, multiplied by 60 residents, have to go somewhere, so they fall on senior residents and attendings.” The program has a tough time attracting and keeping Assistant Chiefs of Service (ACS's), Awad said, because much of the burden falls on them. Having finished their residencies, they operate and teach without protection from the duty-hour rules.

Surgeons overwhelmingly call for the hiring of more physician assistants and nurse practitioners (known collectively as “midmeds”) and more hospital staff trained to draw blood, process X-rays, transport patients, and counsel families about after-care plans. And in fact, since Freischlag began to lead the surgery department in March 2003, she has upped the number of midmeds and instituted an internship for select physician assistants. She also hopes to purchase hand-held computers that update wirelessly, soaking patient information out of the air while surgeons do other things.




Compliance problems in the huge Department of Medicine's residency program are much trickier to solve. It might be counter-productive, for example, to hire more midmeds. Patients admitted to the hospital these days are sicker than they used to be, and their stays are shorter. And so, more than ever, the day of admission is a critical moment in patient care and intern education. That's when tests are ordered, diagnoses made and treatments begun.

“We don't want interns asking physician assistants for answers, because they'll get them,” says Jonathan Murrow, one of the four ACS attendings who perform Herculean feats of resident education in Medicine. “It can be too easy to sign out to a knowledgeable PA. When they sign out to me, I may not answer their questions. I'll turn it into a teaching moment.”

“We think our department has the most front-loaded residency program in the country,” says Mike Weisfeldt, who heads Medicine. “And it works. In the first year, we want interns to do three things: take full responsibility for their patients, learn to manage patient care, and develop their medical judgment.”

That difference puts Medicine in the hot seat, because regulators naturally see interns, the newest and youngest doctors, as those most in need of protection. And the demands on them in this Hopkins program are intense. It was, after all, a new intern rotating through the general medicine service here who lodged the complaint in 2003 that led to the ACGME's threatened withdrawal of the program's accreditation. The Surgery program was not affected.

Richard S. Ross  
Fifth-year resident Michael Awad has now reached the demanding zenith of his surgical training program. Here we follow him through one two-hour period on night duty.

Amar Krishnaswamy, 29, a resident who started his medical internship the day the rules took effect, strives to find enough work time to learn what he needs to know. “I've learned the most in the middle of the night, when I'm the one who has to figure things out,” he says. “If someone looks not quite right in the ER, and you watch that patient through the day and night, running tests and getting back lab results, you learn to take care of that patient. But you also learn to see what they'll be like in eight or 10 hours. You learn to see what is going to be wrong with them.”

Because that kind of long-term contact with patients fosters doctor-patient bonds and continuity of care, Weisfeldt and Residency Director Charles Wiener have changed the basic work schedule to meet the house staff's demand for overnight call while still satisfying the ACGME work-hour limit. “Under the first schedule we tried,” Weisfeldt says, “interns were coming it at 8 a.m. and going home at 2 p.m. the next day. That's when their 30 hours were up. It didn't work, because in hospitals things tend to resolve late in the afternoon, after the test results come back. The interns were missing out on all the good stuff, not getting what they had been waiting all day to find out. Now we have them come in at noon and leave at 5 or 6 p.m. the next day. We think it works better.”

To help with the work load, Medicine has brought in a group of hospitalists, board-certified doctors who only treat hospitalized patients and have no outside practices. They manage care for 16 beds in a separate part of the hospital and step in for assistant chiefs of service two weeks at a time, so these exceedingly busy attendings can have time off.

Finally, Medicine has introduced supervised sign-offs. The department took what it considered a liability—verbal transfers of patient care—and turned it into a teaching opportunity. Senior associate residents like Julie Scialla and David Cosgrove oversee sign-offs between their younger peers. The small group confers about symptoms, tests, treatment options and the virtue of one medication over another.

“The attendings give us a crack at it,” Scialla explains, but later in the day each patient's case is reviewed on rounds by an ACS attending or faculty member.

On a recent morning, Susan Bell, 31, who'd been on duty all night, strode down the hall to get ready to sign off. A slight woman with blue eyes, a British accent and well-worn clogs, Bell says, “I lost 10 pounds my first month,” as she hurtles toward the lounge. As a night admitting team officer, aka night float, Bell takes histories and physicals of new patients when the emergency room is busy and no intern is available, then turns them over to a resident. Since 2003, the float system has expanded to free up time for interns to manage and learn from the care of patients already admitted.

Bell's sign-off is completely different from the one in Surgery. She takes a seat in the midst of a dozen residents and medical students, each sitting in a wheeled armchair. Faculty supervisor Thomas Traill brews Red Horse tea on a hotplate and takes a cup to each of his young colleagues as Bell begins her summary. She wields a six-page report for one patient, not a one-page report for 22 patients. Although she is transferring the patient to intern Timothy Burns, he sits behind her and listens while she addresses senior residents Scialla and Cosgrove. Bell recounts the patient's entire history and array of symptoms before Scialla questions her. Then the two residents talk with Burns about the pros and cons of various medications.

“No matter how detailed the sign-off,” Burns says later, “you definitely feel more connected to the patients you have admitted yourself. You know those people. You've heard their stories, done their physicals. But you take care of whoever is sickest, no matter who admitted them.”




In the end, the lingering impression is that, despite the turmoil the new guidelines may have stirred, they are working—better all the time. And because they are certainly here to stay, it's probably time for everyone to stop feeling conflicted. The risks of resident fatigue are real. Even in a recent utterly informal survey here, eight out of 14 physicians admitted they'd fallen asleep at the wheel. Awad said that as an intern, he woke up on the wrong side of the street, with oncoming traffic rushing toward him. Traill said he totaled his car but walked away unscathed.

Economics, it's true, favor long resident work hours. House staff salaries at Johns Hopkins, paid mostly by Medicare, start at $41,655 and rise about $2,000 per year—roughly $10 to $12 an hour for the first five years, assuming an 80-hour work week. “Residents are incredibly cheap labor . . . on a per-hour basis,” says Chris McCoy, legislative affairs director of the American Medical Students Association.

Considering, also, the huge amount of time and organizational change it's taking to maintain the unusually high level of patient care that Hopkins is known for, might one of the programs be tempted to ask the ACGME to change the rules?

“Don't even think about it,” says Bill Baumgartner, chief of cardiac surgery. “The rules are here to stay. It's time for us to stop whining about them.”

Awad actually may have expressed best what's happened since 2003. As he worked on the two surveys, he says, he watched his colleagues go through the classic stages of grieving. “First we were in denial, thinking it couldn't happen here. Then we got angry, and now, finally, we are accepting it.”

“I think 80 hours is a good thing,” Freischlag says. “Before the rules, many young doctors were damaged by their training, but you'll never meet them. They got anxious and depressed; they drank. In my own surgery residency program, two killed themselves. The survivors look great, but what about the ones who might have become good doctors, but who didn't finish?”

She pauses, then makes one final statement: “We had to accept the change. Now we're going to champion it. Hopkins is going to do it better than anywhere else in the country.”


 The House that Sol Built
 Time Clocks in the Trenches
 Beyond the Abyss
 The Sum of All Fears
 Circling the Dome
 Medical Rounds
 Bench Press
 Annals of Hopkins
 Learning Curve
Johns Hopkins Medicine

© The Johns Hopkins University 2006