A difficult equation

By: Stephanie Shapiro
Date: February 22, 2011

In response to new duty hour standards, Hopkins residency programs must reckon with competing demands.

As the July 1 deadline approaches for meeting new house staff duty hour requirements, school of medicine program directors are poring over a devilishly complicated logistical puzzle: How to match up existing staff with shorter shifts while preserving patients’ safety and residents’ educational experience.

The new rules, issued by the Accreditation Council for Graduate Medical Education (ACGME), limit first-year interns to shifts of no longer than 16 hours—eight hours less than currently—and spell out the supervisory role of senior residents and attending physicians in greater detail. Developed because of concerns about resident fatigue and insufficient supervision, the revised standards also require that more senior medical staff be immediately available, either in person or remotely.

Such changes should improve overall communication and teamwork, but they will also upend the residents’ familiar routine, according to Julia McMillan, associate dean of graduate medical education. “It boils down to fewer weekends and less chunks of time off, plus less day time available,” she says. “It will really cut down on the free time of more senior residents and faculty. They will need to be more available to supervise.” And though residents can still work 80 hours a week, she says shorter shifts mean they must spend more of their time in the hospital on night-only assignments, foregoing essential training activities such as working in clinics and the OR and attending conferences.

“We have to make some kind of accommodation to provide them with the education they need to get,” says McMillan, who also directs the pediatric residency program at the school of medicine.

Squaring the need for standards and experience

Finding the right formula for meeting the ACGME’s one-size-fits-all standards presents a significant challenge for each residency program. How, for example, can first-year surgical residents assist with surgeries if they have to go home every morning after an overnight shift? How will smaller programs fill in staffing gaps created by shorter shifts? How will internal medicine residents follow the natural history of a disease if they have to leave a patient at quitting time?

Fourth-year surgical resident Manny Pappou worries about the effect of decreased hours of continuous care. “Some people have recurring problems,” he points out. “You need to know the patient well. If a patient vomits, you have to know if it’s related to a new problem that occurred or a chronic problem; the way you approach it is totally different.”

A native of Greece, Pappou came to The Johns Hopkins Hospital in part because he considered European residency programs too lax. Now he fears the new duty hour standards may threaten the rigor of such programs in the U.S. “Surgical training is unique. It takes a lot of time to acquire dexterity and cognitive ability. There is no shortcut.”

What is an optimal shift length? The American Medical Association says that the 16-hour shift adequately addresses patient safety and resident well-being. But other professional organizations, including the American Academy of Family Physicians, say that the new duty hour restrictions hinder the training of first-year residents.

The debate is not new. The first set of duty hour standards, issued by the ACGME in 2003, ended the era of 100-hour work weeks by imposing an 80-hour ceiling and limiting first-year resident shifts to 24 hours with certain exceptions.

The more recent drop in shift lengths, however, signals a wholesale culture shift from the residency model established by William Halsted and William Osler, two of Hopkins Hospital’s most revered figures, says Pamela Lipsett, director of surgical education at the school of medicine:  “It’s completely not Halstedian or Oslerian in the following way: You work as hard as you can, but the moment your shift is over, you pass the work over.”

Lipsett shares the view of many that no studies have yet proven that extended resident shifts lead to patient harm. But she does believe that the duty-hour decrease can hasten the transition to a more team-based approach to surgical care, a model she has long advocated for. She says the guidelines “really mandate a group mentality. Now it’s absolutely essential to take yourself away from the idea that you are a sole practitioner and toward your role as a productive group member.”

Another thorny issue for residency programs is the cost of compliance. The Institute of Medicine has estimated that it will cost about $1.7 billion for the 8,700 residency programs under the ACGME’s scope to meet the standards. Compounding the challenge, “physician extenders,” or physician assistants and nurse practitioners, are in short supply. 

“Clearly it takes additional resources,” Lipsett says. “We have a plan for meeting the new requirements, but we are going to need more help. In surgery, there are activities that occur only during the day, like elective surgery, which means residents who must spend time in the operating room will be working less at night. We need to have midlevel clinicians who aren’t residents to take their place.”

                                                The effect of greater supervision

The new guidelines will ensure more comprehensive supervision of new residents, says McMillan, overall a fan of the ACGME changes. “A younger, more inexperienced person, usually an intern, needs to be supervised by at least a more senior resident,” she says. Similarly, “The more senior residents need experience supervising and teaching interns. There are residency programs here where neither of those experiences happens all the time.”

Even though she has no quibble with making senior residents readily available to interns, Lipsett worries that too much oversight may hamper their learning unless it comes at the right stage of their development.

“I think there’s real concern about whether there will be a loss of learning related to the autonomy that currently exists in afterhours,” she says. “There are some real data to prove that autonomy is at some point absolutely necessary to achieve learning,” says Lipsett, citing for example a recent article in the Journal of General Internal Medicine. That said, Lipsett says the rules rightly acknowledge that independence must come “at the right developmental stage. You need to have the appropriate skills to have autonomy.”

Plastic surgery resident Rachel Bluebond-Langner agrees that it’s difficult to strike a proper balance between adequate training and assuring that residents are fit for work. “What’s so magical about 16 hours?” says Bluebond-Langner, who was one of the first residents to experience the 80-hour work week. “As a surgical resident, the concern is that if you’re only allowed to work 16 hours, you miss valuable time in the OR.” 

The new restrictions will require more handoffs, making patient care even less personal, says Pappou, who is vice president of the House Staff Council. “There are so many things that you cannot convey through a sign out,” he says. “You cannot transmit your own feeling of personal responsibility and if you are taking care of a patient for only eight hours, you won’t learn as much.”

McMillan points to the pediatric residency program’s current duty hour schedule, in place since 2003, as one formula for minimizing the disruption of the newly mandated restrictions.

”We have had a day and night team of residents, so they’re only gone for 12 hours and then they come back. They only have to sign out twice a day and coverage overlaps allowing for more thorough handoffs,” she says.

What’s more, McMillan says, residents no longer fall asleep routinely at the noon conference. “They’ve been in their own beds the night before, and when they’re here, they’re awake.”