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On Being a Doctor |

Unintended Consequences: The Accreditation Council for Graduate Medical Education Work-Hour Rules in Practice

Jason Ryan, MD, MPH
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From Beth Israel Deaconess Medical Center, Boston, MA 02215.

Requests for Single Reprints: Jason Ryan, MD, MPH, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215; e-mail, jryan2@bidmc.harvard.edu.

Ann Intern Med. 2005;143(1):82-83. doi:10.7326/0003-4819-143-1-200507050-00014
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Seventy-nine-year-old Doris K. was admitted to the hospital with weakness at a bad time for my team and me, especially considering the limits of the new 80-hour workweek. It had been a frenetic day. We were swamped with 11 patients who came before Doris K., and her weakness brought us to a dozen. Keeping up was exacting, made worse by the pace: Six new admissions hit the floor in just 3 hours. As one of the interns succinctly put it, we were “getting spanked.” But in addition to the volume of admissions, our night felt increasingly overwhelming from a unique and novel burden: We had to finish everything by 11:00 p.m. Each of us did the math and tried to conceive of a method of seeing 5 more patients and leaving the hospital in the next two and a half hours. It couldn't be done, and realizing this made us feel exponentially more frazzled, rushed, and suffused with fatigue. This was medical training under the mandatory work-hour restrictions for physicians.





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Intended consequences
Posted on July 8, 2005
Ellis M Knight
Palmetto Health
Conflict of Interest: None Declared

As a long time practicing internist/hospitalist, who trained well before the recent resident work restrictions, I feel compelled to respond to Dr. Ryan's contention that unintended negative consequences are resulting from the recent changes in resident work schedules. I contend that these consequences may very well be intended and in fact are constructive when considered in the context of the work environment these housestaff will face in the future.

In my twenty plus years of private practice, the healthcare reimbursement system has forced practitioners like myself to push productivity to the limit. Intellectual curiosity must often be sacrificed in the name of efficiency. The satisfaction of thoroughly understanding a patient's illness by delving into a problem with the diagnostic rigor I was taught in training is a luxury I am now rarely allowed. I agree with the author's sentiment that the current limitations on resident's work hours may distract from their ability to learn the nuances of pathophysiology and to gain exposure to therapeutic and procedural modalities. Despite this,the practical skills today's residents are learning about how to efficiently evaluate and treat large numbers of patients as quickly as possible may prove to be more valuable in the real world than some of those my generation had the luxury to develop during our training.

Dr. Ryan and others may not want to hear this but my ability to see 30 or more patients a day is of much more value to me now than being able to recite from memory the differential diagnosis of hypercalcemia.

Conflict of Interest:

None declared

The Vicious Cycle of Work Hour Restrictions
Posted on July 7, 2005
Steven J Zanders,DO
St. Luke's Hospital and Health Network
Conflict of Interest: None Declared

I read with nodding agreement Dr. Ryan's comments on the new paradigm of work hour restrictions. Having been a part of the old as a resident and the new as a fellow and attending, I have encountered the same phenom. I believe we are creating less experienced, less knowledgeable physicians for a myriad of reasons. One of which are the exra hours of work that are now added to our already burdened days. In our institution, attendings are working more hours and have a schedule much like we did as interns/residents. Because our day is rushed and harried, there is a tendency to teach less. I have also noted a lack of patient ownership and a shift work mentality in our resident staff. Residents are more concerned about their hours then learning and knowing their patients. The time they were meant to have gained to be better educated is sought pursuing other interests. So the cycle is now perpetuated. Attendings work more, teach less; residents work less and learn less. How long will it be before we fall into the same trap? Somewhere in the middle is a healthy balance and it may take some time for the pendulum to swing to the middle.

Conflict of Interest:

None declared

Re: Intended consequences
Posted on July 12, 2005
Sam Wong
JLP VA Medical Center/Loma Linda University
Conflict of Interest: None Declared

Although I concur with the major observations of article by Dr. Ryan, it was unclear to me whether he offered any viable solutions. Trained in the "old fashion" way of the last century, I maintained my commitment first to our patients. When mandated poorly-thought out regulations interfere with the care of my patients, we are mandated by an even higher calling - the Hippocratic Oath. With this perspective, to this day, when I attend on the wards (2-5 months a year), I take no day off. I give up my entire call month to the housestaff. I take call from 8-11 AM (carry the code pager, write admit orders, triage admits, etc...just like a resident), stay with the team through the night until about 2 AM (have to go home and see my family asleep) and return in 5 hours with fresh fruits and breads (no donuts). Since I will have seen of the patients and know pretty much all the test results by the post-call morning, I am afforded the time to actually teach during the 9-12 attending rounds. As the patients are admitted on the call day, I review the EKGs and other tests with the team and teach them at the bedside. Only in this manner can the astute and seasoned physician learn with the team how the "flower blossoms." Instead of having students recite lab results that I already know, we actually go to the Micro lab to check on the cultures, review with the Pathologist fresh biopsies, review with the Radiologists images taken, review with the Cardiologists actual echo images, and even consult as a group with subspecialists on a daily basis. To maximize the team's efficiency, I embrace technology to recouncile the tedious chores. No longer do we "hunt down" the xray or EKGs - they are accessible by the wireless Tablet that I bought for my team. All orders are entered electronically. We communicate with ISP phones and two-way text pagers. Even though "copy-paste" notes are outlawed, intelligent templated notes have reduced the documenation time. We even have time to send detailed, instructive "Thank You for being hospitalized at our facility" letters to patients after they are discharged. A strategic member on the team is a responsive and responsible nurse-case manager who can implement orders efficiently. We emphasize addressing only the acute reason(s) for acute hospitalization. Addressing non-acute and non-medical issues displaces valuable housestaff time and resources. (Just as a surgeon should not need to address onychomycosis in a patient with acute appendicitis.)Although I do not advocate my colleagues to use this model, many have adopted some aspects of this model. This approach appears to be the only viable solution to maintain our promise to our profession, our housestaff and students, and especially to our patients.

Conflict of Interest:

None declared

Unintended consequences of the ACGME changes on the hospitalist movement
Posted on August 3, 2005
Jeffrey J Glasheen
University of Colorado at Denver Health Sceinces Center
Conflict of Interest: None Declared

I share Dr. Ryan's concerns for the future of internal medicine training and agree that the recent ACGME changes may negatively impact resident education.1 Dr. Ryan's last sentence, "the system (of training) molds us into doctors, and as doctors, we will define the U.S. health care system in years to come," leads me to posit another potential unintended consequence of the ACGME changes"”namely the effect on the hospitalist movement.

The past decade has seen a rapid rise in the hospitalist model of care with most institutions utilizing some form of a hospitalist service. The reasons for this growth center on hospitalists' ability to improve the quality of care in a resource-friendly manner. However, achieving these outcomes assumes that physicians possess expert triage skills and can operate at a high level of efficiency. Indeed, handling large patient volumes in an efficient manner is the sine qua non of the hospitalist movement. While the average community hospitalist sees approximately 15 patients per shift many groups routinely push this number to 20 and even as high as 30. While the merit of pushing for these very high patient numbers is questionable the fact remains that the success of the hospitalist movement hinges on the ability to maintain positive outcomes in the setting of high clinical loads. Most practicing hospitalists were trained in a prior era where trainees were forced to see large volumes of patients, triaging the sickest in a highly efficient manner. Contemporary trainees are limited to admitting 10 patients per 24-hour period and seldom follow a service of more than 15 patients per day. One wonders how well a graduating resident who has rarely cared for more than 15 patients at a time (with the assistance of an attending, interns and students) will function when faced with a daily service of 15-20 patients. Will he/she be able to maintain these improvements in patient outcomes and resource utilization? Ultimately the answer to this question may determine the future of hospital medicine.

While it is hard to argue with the spirit of the recent ACGME changes or to advocate for higher patient loads it is likely that these changes will have a profound impact on the hospitalist movement and the care hospitalists give their patients. Ultimately, as Dr. Ryan suggests, the success of the U.S health care system will depend upon how well the ACGME can manage these, and other, unintended consequences.

1 Ryan J. Unintended consequences: The Accreditation Council for Graduate Medical Education Work-Hour Rules in Practice. Ann Intern Med. 2005;143:82-82.

Conflict of Interest:

None declared

Author's Response
Posted on October 11, 2005
Jason Ryan
Beth Israel Deaconess Medical Center
Conflict of Interest: None Declared

I agree with Dr. Knight's assertion that the ability to triage and efficiently manage large numbers of patients in a short amount of time is an essential skill for modern physicians. He rightly points out that time pressures exist outside of residency programs and are ubiquitous in today's healthcare system. As I wrote in Unintended Consequences, the time constraints on residents have many sources and were increasing even before the new work hour rules. Nevertheless, I worry about the effects such onerous time pressure on physicians right from the starting blocks of their education. As Dr. Knight points out, physicians of his generation had time during training to delve deeply into their patient's problems. This undoubtedly prepared them for later stages of their careers when the healthcare system forced them to do more in less time. For my generation there is no such warm up period. From day one of internship, we manage large numbers of patients in a severely restricted amount of time. How will we learn to effectively triage with only limited and often cursory observations of disease progression over time? How we will competently manage patients if we have always handed off the difficult decisions to specialists in the name of timeliness? Although we may be learning the important efficiency skills Dr. Knight writes about, I wonder if we have obtained them at the cost of education. I appreciate the comments of Dr. Zanders and agree that attending schedules have been affected by the work hour rules as well. One way to push back against the time crunch is to have academic medical leaders who emphasize quality care. If we reach a point where attending physicians also find there is no time for learning, we will have lost an critical resource.

Conflict of Interest:

None declared

Re: Author's Response
Posted on November 24, 2005
Steven P Praske
Maine Medical Center
Conflict of Interest: None Declared

I believe that all of Dr Ryan's concerns are well-founded. Yes, there is a "disconnect" between the medicine we practice during training and that which is practiced in the "real world". I completed internship under the old system before practicing as a generalist in the navy for three years prior to returning to residency training. Seeing 30 outpatients in a day ( this may be a light load for many)was completely foreign to me.

However, I still believe that the goal of a training program should be to educate the resident. Emphasizing volume, productivity, and efficiency in processing patients may make life somewhat easier for a short time after entering the work force, but this does not translate into better outcomes in patient care. During training, it was the time I spent thinking about my patients, generating diffential diagnoses and treatment plans, and then having a thorough discussion with my attending physician that prepared me to interact with the individual patient.

As it stands now, volume and hours are not limiting factors in terms of quality of education. Where I train, residents run a service of 15-24 patients, many of whom are very sick. There is little "free time" to contemplate on a deep level. Call days/nights are a sprint from 0600 one day to 10:30 am the next to see the "old players" and to evaluate and admit the "new players". The journey itself is a learning experience, but the deaper learning points are necessarily postoned for another day, which is unlikely to come under the current system. "If we could just diurese down to 15 or so patients", then maybe there would be time for teaching.

Some here have argued that time constraints contribute to this problem or that residents are "working less". The assumption that working more hours would solve the above problem is not logical. I remember post call days under the "old system" in which I would have a clinic from 1:00 pm to 6:00 pm. I can tell you that I was not there to learn, but just to do my best to attempt to hear my patients and not to make a mistake. Luckily the attending physicians understood this and their expectations were justifiably adjusted downward.

Under high patient volume ( which is most of the time ), both residents and attendings are overextended. Teaching becomes minimal to non -existent, and all rounds are "work-rounds". Increasing volume will not help us as physicians now or later in the "real world". A return to 36 hour duties or extending the 80 hour limit does not add to the educational or practical experience. It is important to remember that residents are still in a learning mode. This is often forgotten and productivity/effiency takes priority over learning.

Conflict of Interest:

None declared

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