In 2003, the Accreditation Council for Graduate Medical Education (ACGME) placed restrictions on resident duty hours (RDH). The new regulations limit residents to an average of 80 h/wk, with the length of a shift limited to 24 hours with up to 6 additional hours for continuity and transfer of care. In addition, 10 hours off between shifts and 1 day free of scheduled patient care per week are mandatory.1 Theses rules were adopted in response to legal pressure2 and a body of literature3–12 suggesting that ill effects on patient care and residents’ health and quality of life could result from the acute and chronic sleep deprivation associated with long working hours.13 Despite these findings, some in the academic medical community raised concerns about the new regulations, fearing a negative impact on residency training quality and preparation for the realities of practice after graduation.14–17
We were interested in program directors’ perceptions and experiences after the first full year of RDH restrictions. Literature searches identified five previous studies of the perceptions of residency program directors (PDs) about the effects of limiting RDH on residents’ training environments.18–22 Lieberman et al18 compared surgical and medicine PDs’ concerns and found that most anticipate improved patient safety and resident well-being as results of the reforms. Surgical programs were more likely to hire new staff. Decreased education, reduced continuity of care, and lower pass rates on board certification exams were common concerns. Most otolaryngology PDs described making “minor” changes, such as scheduling, to be in compliance, but most agreed that RDH limitations had not produced the intended improvements.19 Sixty-eight percent of neurosurgery PDs hired ancillary personnel, with 84% feeling this did not limit their residents’ clinical experience; however, 93% believed continuity of care had been disrupted, and 79% felt the ACGME guidelines had negatively affected their training programs.20 A survey of otolaryngology head and neck PDs found that 71% of programs had to change work schedules and that 32% had hired new staff. Eighty-four percent believed the ACGME standards did not improve patient care, and nearly as many felt residency training had been negatively affected.21 A survey of pediatric PDs found that large programs were more likely to implement a night-float system and use cross-coverage.22 About half of PDs hired new staff, and most reported loss of continuity, decreases in the amount of time spent in inpatient settings and flexibility of residents’ schedules, and increased logistical work.
The perceptions and attitudes towards RDH reform among PDs in family medicine (FM) remain unknown. Because FM residencies produce the greatest number of graduates practicing primary care,23 family medicine PDs (FMPDs) must ensure that their trainees receive both the breadth and depth of graduate medical education required to deliver the comprehensive, continuous care required of them on graduation. As such, FMPDs are critical to high-quality primary care education, and their perceptions are key to our understanding of how RDH reform affects the knowledge and skills of new primary care physicians. The aim of this study is to assess how FMPDs perceive the way in which the new ACGME standards have affected their programs 1 year after implementation.
After surveying relevant literature to establish content domain, in 2004 we developed a questionnaire in conjunction with the Medical Education Division of the American Academy of Family Physicians and piloted it with nonrandomly selected FMPDs. After appropriate revisions had been made, an e-mail invitation to participate in an anonymous Internet-based survey was sent on two different occasions to all 472 FMPDs via the Association of Family Medicine Residency Directors list-serve. The e-mail cover letter explained that all responses would remain anonymous and that completion of a survey was presumed to constitute consent for participation in the study.
The survey instrument (Appendix 1) contained two closed-end questions about hiring new staff in response to the RDH regulations and about how training experiences of residents had changed as a result of doing so. Eight closed-ended, scaled questions with answer choices of “increased,” “no effect,” and “decreased” assessed the changes in time spent on various educational activities within the residency. Two additional open-ended questions asked for concerns about how RDH restrictions were affecting residency training broadly and residents in particular.
Our analyses were mostly descriptive because we did not collect data on the characteristics of residencies and PDs. Responses to the scaled questions were counted and cross-tabulated. Thematic analysis of free text responses was performed independently by three of the authors (LP, AB, RP) before group review and resolution of themes.
Between September and December 2004, the Internet survey site received 390 hits, where 369 FMPDs completed at least some questions, 328 completed all of the closed-ended questions, and 270 responded to the open-ended questions. Using the 472 FM residency programs in existence in the fall of 2004 as a denominator and completion of the closed-ended as a numerator, this constitutes a response rate of 69% (328/472) for complete responses. Because this was an exploratory, descriptive endeavor, our analyses include all responders, partial and complete.
Half of the respondents indicated the RDH restrictions increased patient-care duties for attending physicians, whereas 42% reported no effect. Nearly 60% of respondents indicated that there had been no effect on time in teaching rounds, but 47% noted a decrease in formal educational activities. Loss of elective time and fewer on-call days were reported in 40% of programs. Slightly over half of the programs reported having lost rotation time in specialty and continuity clinics (Table 1).
Seventy-seven percent of responding FMPDs did not hire additional staff in the first year after RDH restrictions. Five percent reported a decrease in staff, and 18% reported hiring more staff in response to the RDH restrictions.
Of the 65 FMPDs who reported hiring any new staff, 42% had hired additional physicians, 11% had added more residents, and 17% and 20% had added physician assistants (PAs) or nurse practitioners (NPs), respectively. Hiring a nurse or other staff member was rare, but increasing administrative staff occurred in 20% of these programs (Table 2). Cross-tabulation of hiring numbers revealed that no program had increased both the number of residents and number of PAs, NPs, or nurses. Only one program reported hiring both a PA and an NP. Five programs had increased the number of both physicians and PAs/NPs. Three programs had added both residents and physicians.
Among the 168 FMPDs indicating an increase in attending physician time spent on patient care, only 20 had hired new physicians. In contrast, only one program indicating “no effect” on time spent by attendings in patient care had hired new physicians. Trends in hiring by these programs mirrored the overall trend of programs that had increased staff, with the emphasis foremost on hiring more physicians, then PAs/NPs, then administrative staff and residents, and, finally, adding nurses or other staff (Table 3).
In response to a question about the RDH regulations and their effects on residents’ training experiences, nearly 60% of FMPDs reported eliminating postcall clinic duties (Table 4). About one third of residencies had adjusted resident work schedules or created a new night-float system, with 5% (17 total) implementing both changes. Residencies that had eliminated postcall duties were almost twice as likely to have implemented a night-float system instead of adjusting schedules (46% versus 25%). One fifth of respondents checked “other” and entered their own responses. These responses fell into four broad categories: increased faculty work load, less continuity of care by residents, residents missing educational opportunities, and changes in postcall clinics or didactics.
Qualitative analysis of FMPDs’ responses to question 4, “What are your concerns regarding how work-hour regulations are affecting your program?” fell into five broad categories: (1) decreasing educational opportunities and quality, (2) decreasing continuity of care, (3) residents not being prepared for real-world practice, (4) development of a punch-clock mentality/erosion of professionalism, and (5) increased administrative burden. In addition to these five themes, infrequent but vocal concerns arose about the conflict between curriculum requirements for residency and the RDH regulations. One FMPD stated, “I submit it is impossible, within the parameters of [State law NY 405s] and to a somewhat lesser extent the ACGME regulations, to honestly fulfill program requirements as they exist today!” FMPDs reported that the most problematic RDH requirement was 10 hours off between shifts. There were few, albeit strong, calls to compensate for the loss of educational experiences by lengthening residency training. Although responses generally offered statements of disdain for RDH reform, many offered no major concerns.
Qualitative analysis of FMPDs responses to question 5, “What are your concerns regarding how work-hour regulations are affecting your residents and their training?” fell into four broad categories: (1) decreased educational opportunities and quality, (2) decreased continuity of care, (3) decreased ownership of patient care, and (4) development of a punch-clock mentality/erosion of professionalism. These themes are explored in depth below. A small minority of FMPDs felt that the changes made residents better off, and fewer than half the FMPDs had no major concerns or had already been in compliance before the new standards began.
FMPDs expressed concern about the development of a punch-clock mentality and its subsequent erosion of professionalism. There were reports that some residents no longer cared about what happened to their hospitalized patients once they were off the clock. One commented, “Residents feel more like clocked employees, less like professionals. It’s not ‘my’ patient.”
Respondents also reported that limiting the hours residents work has encouraged a mentality of entitlement to their free time and lack of consideration for patient needs. For instance, “Residents are becoming clock watchers rather than professionals who ask what my patient needs.”
The lessons gained by working long hours and knowing one’s limits were cited frequently, and as one FMPD so eloquently stated, the RDH regulations “make it easier for average people to enter and pass the tests of character and mettle which have in the past made being a doctor something special, something not everyone could do.”
Preparation for practice
One respondent asked, “How will these doctors cope in real practice?” Many FMPDs expressed concern that residents are not being adequately prepared for the conditions of private practice, where no work-hour limits exist. Similarly, there are concerns that residents are developing false expectations that medicine is strictly a “9 to 5 job” and that someone else can finish their work. For instance, “We are creating physicians now more than ever who are going to be going out into the workforce looking to perform shift work. It is going to be a rude wake-up call when these physicians begin their private practice careers. We owe it to our residents to create a demanding but tolerable environment, rich in experiences that will benefit them for a lifetime.”
Impacts on education/continuity of care
Loss of postcall activities and subsequent loss of continuity were the major educational concerns of FMPDs, as this comment illustrates: “Less time in specialty clinics; less time on inpatient teaching rounds post call; both equate to less experienced residents.” In the view of most FMPDs, decreased time providing care equates to less experience and less preparation for the real world. Many FMPDs felt that this lost time must be made up for.
Missing out on obstetrical care continuity was brought up often. One scenario that was cited a number of times involved a resident providing all the prenatal and maternal care and then being sent home during the delivery because the resident had exceeded 30-hour limit for continuous duty. On inpatient services, many FMPDs felt that residents had lost valuable educational experiences by not having to see patients through all of an admission because they were in violation of the RDH regulations.
The new RDH regulations have affected FM residency programs in many ways. Our study found that answers to questions regarding the change in time spent on various activities were split between “no effect” and those indicating negative outcomes, suggesting that the RDH regulations have not had a consistent effect on FM residencies. It should be noted that about 4% of FMPDs felt their residents were better off under the new duty hours limits. One commented, “I think these regulations are reasonable and necessary. My residents have a better life than I did, and I’m glad.”
Most FMPDs reported using a variety of strategies to comply with RDH regulations. Similar to a previous study,24 we found that 50% of residencies reported an increased workload for attending physicians, but we were unable to verify whether the hours attendings work actually had changed. Two studies of surgical attendings demonstrated conflicting results, with one showing that the hours worked did not change after implementation of RDH regulations25 and another finding more work and stress and less job satisfaction.26
We found that few FMPDs responded to perceived increased workloads by hiring new staff, as evidenced by less than one in five programs (18%) hiring additional clinical staff. Hiring NPs was twice as common as hiring PAs among all programs who had hired new staff (20% versus 11%) and among programs reporting an increased faculty work load (4% versus 2%). This finding is consistent with prior studies showing the hiring of NPs/PAs to be a common method of compensating for decreased patient care by residents.18,21,22
Postcall clinics were eliminated in 60% of residencies, and more than one third of residencies adjusted resident work schedules or began a night-float system. FMPDs reported that administrative burden had increased because of cancelled clinics and rearranged schedules. One FMPD responded that having to accommodate lost postcall clinic times had “escalated scheduling from a minor headache to a screaming nightmare.”
Calls to make up for lost educational time by increasing the length of residency training are not unique to the respondents of this survey,27 and the issue of whether FM residency training should be extended had been debated before implementation of the RDH regulations.28,29 With the loss of educational time and concerns of FMPDs, there may be renewed interest in extending FM residency training.
The phrases “punch-clock mentality” and “clock watching” arose often in our qualitative analysis. These statements were usually linked to others indicating a loss of professionalism in residents. Our survey captured perceptions of FMPDs one year after implementation of RDH reform; we hope these programs have now struck a balance between respecting residents’ time off and fostering a sense of professionalism and duty toward patients.
Impacts on education/continuity of care
With less time spent in training, residents’ time must be prioritized to enable quality learning experiences. The way in which residents spend their time may not be optimal; Vidyarthi et al30 have shown that residents’ time spent on administrative activities had not changed under RDH restrictions. Similarly, our findings show that less time is spent participating in formal learning activities such as didactics and journal clubs. Many FMPDs indicated that this time must be made up somehow; otherwise, residents will enter the workforce without the necessary skills and knowledge to practice medicine.
Loss of continuity of care was also a major concern of FMPDs. Before RDH regulations, residents could sleep for 4 hours and then attend an afternoon continuity clinic, but they now must be off for at least 10 hours.
Limitations and future research
This study has several limitations. First, we did not collect data on the characteristics of residencies or FMPDs, preventing comparisons by residency size, type (university versus community hospital), and characteristics of the FMPDs (e.g., age, years as a director). Second, there is a risk of recall bias, which we expect to have been minimized by the survey administration just 1 year after the implementation of the RDH restrictions and the likely ongoing nature of responding to these restrictions. Third, response bias is possible, but the high response rate for a physician survey sample should minimize any effect. Last, we made no objective measurement of the effects of RDH regulations on residency training programs; we only measured the opinions of FMPDs. We recognize the possibility that FMPDs might perceive that the workload of their faculty has increased when, in reality, it has not. Despite these limitations, we believe our findings represent a valuable first look at the issues FMPDs face in implementing the new RDH regulations. Follow-up studies should address the need for objective measurement of duty hours simultaneously with PD and resident perceptions. In November 2005, the Association of American Medical Colleges issued the “Compact Between Resident Physicians and Their Teachers,” which holds “respect for residents’ well-being” as a core tenet of residency education.31 Concerns for residents’ well-being have now been codified in the medical world, and further research should investigate the unique ways that programs have adapted to life in this new world.
To our knowledge, this study is the first to address the concerns of FMPDs about the new RDH regulations, and it reveals that the effects of implementation are variable across programs. None could argue that residents do not lose educational experiences under the new RDH regulations; however, the debate should now focus on how to compensate for those losses. We suggest that if innovations for increasing the effectiveness of teaching cannot make up for the educational losses, then extending the length of residency training must be considered.
This study was funded by The Robert Graham Center, the American Academy of Family Physicians, and the Association of Family Medicine Residency Directors.
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