Editor’s Note: This is a commentary on Roshetsky LM, Coltri A, Flores A, et al. No time for teaching? Inpatient attending physicians’ workload and teaching before and after the implementation of the 2003 duty hours regulations. Acad Med. 2013;88:1293–1298.
The untimely death of Libby Zion in 1984 triggered widespread concern for the role that sleep deprivation and fatigue play in threatening patient safety and increasing medical errors. Her well-publicized death resulted in an inquiry by the New York State Committee on Emergency Services chaired by Dr. Bertrand Bell (the so-called Bell Commission), whose deliberations were transformative, leading to a recommendation to restrict resident duty hours to 80 hours per week.1 The Accreditation Council for Graduate Medical Education (ACGME) broadly adopted this recommendation in 2003. Similar duty hours restrictions exist in other jurisdictions, including Canada, Europe, and New Zealand, though the forces leading to such changes differed in each jurisdiction.
Interestingly, while few would debate the importance of restricting resident duty hours, Dr. Bell himself pointed out, “Although the need to change the working hours of housestaff has received the most publicity, the focus of the recommendations of the committee’s report was on supervision.”2 Indeed, the 2009 Institute of Medicine report Resident Duty Hours: Enhancing Sleep, Supervision, and Safety 3 made explicit recommendations that attending physicians need to provide closer and more regular supervision in the clinical setting, primarily to more junior learners. Sir John Temple,4 in Time for Training, the report on the implementation of the European Working Time Directive, went even further, advocating a model of consultant-delivered after-hour care, in which consultant staff would be physically in-house after hours to supervise residents.
For much of the past decade, however, the discourse has focused primarily on the intended and unintended effects of resident duty hours restrictions on resident well-being and fatigue, patient safety, discontinuity and handoffs, and opportunities for teaching. On the other hand, attending physicians’ needs and perspectives generally have been ignored. Yet, failing to consider the impact of resident duty hours restrictions on attending physicians may have important implications on learner and patient outcomes.
In this month’s issue of Academic Medicine, Roshetsky and colleagues5 report that attending physicians at the University of Chicago Pritzker School of Medicine cited a greater clinical workload since the implementation of the 2003 ACGME resident duty hours regulations, and that this increase in attending physicians’ workload appears to correlate with decreased time for teaching. This finding represents an important addition to a growing body of evidence that suggests that resident duty hours restrictions negatively affect attending physicians’ workload. While prior research on attending physicians’ workload focused primarily on surgical faculty, the study by Roshetsky and colleagues suggests that similar concerns exist with general medicine attending physicians.
Beyond time for teaching, undesirable increases in attending physicians’ workload also can have a negative impact on their availability for clinical supervision. While few prior studies have addressed this specific concern, the available evidence points to a worrying trend that suggests that reduced resident duty hours place a greater burden on attending physicians to themselves provide care to patients, taking time away from providing adequate clinical supervision.6 Thus, a tension exists between the emphasis on reducing the number of consecutive hours worked by residents and the potential for faculty burnout, which may undermine the current ACGME duty hours regulations that recommend increased direct supervision of trainees by attending physicians.
Attending physicians’ increased workload also may create challenges with advancing the broader adoption and implementation of competency-based training and developmental milestones in graduate medical education. To determine whether trainees have acquired specific competencies and achieved the requisite milestones, attending physicians need to be available to directly observe and assess trainee performance in a variety of domains. Again, one might surmise that the increased clinical demands placed on attending physicians would limit the amount of time that they could dedicate to residents’ assessment. Taken together, the prospect of widespread increases in attending physicians’ workload resulting from restrictions in resident duty hours has broad implications for graduate medical education. Not having time to teach may be but the tip of the iceberg.
Allowing increases in attending physicians’ workload to go unchecked will ultimately lead to faculty burnout. In some training programs, particularly surgical specialties, attending physicians already report increased levels of dissatisfaction and burnout, which is a cause for significant concern.7 Physician burnout leads to increased patient dissatisfaction and an increased risk of medical error.8 It also can threaten academic productivity—not only do faculty have less time for teaching, assessment, and supervision but they also have little time left to meet the research expectations set by their academic departments. All of these sources of increased stress may ultimately make it more difficult to recruit physicians for academic positions in the future.
A number of large-scale studies have examined the degree to which resident duty hours reform has affected patient care.9,10 The majority of these studies have not demonstrated any improvements in patient safety or reductions in medical errors, and some recent reports actually question whether such changes may have adversely impacted patient outcomes.11,12 Many name the increased number of handoffs and frequent shift changes as the most likely reasons for such effects. However, the unintended consequences of attending physicians’ increased workload might have an important negative impact on their availability for clinical supervision, which might further explain why patient outcomes have not improved. Therefore, deliberate efforts to address attending physicians’ workload must receive greater attention if the duty hours movement is to achieve its ultimate goal of improving patient care.
In the same way that the 2011 ACGME duty hours regulations require programs to explicitly address patient handoff training, perhaps there is also a need for such policies to encourage training programs to seek creative solutions to address the workforce shortage that was created by these restrictions without necessarily increasing attending staff members’ workload to compensate for the fewer hours worked by residents. In addition, such a requirement is important given that the ACGME duty hours regulations also call for a greater degree of direct supervision of residents by faculty. Many academic medical centers now turn to hospitalist services to offset the additional clinical demands placed on academic faculty. When thoughtfully implemented, hospitalists may not only help to preserve the time available for attending physicians to pursue their research and educational activities, but they also can assume some of the teaching and supervision responsibilities and improve overall trainee satisfaction.13
Regulating resident duty hours remains appropriate and necessary. Although the study by Roshetsky and colleagues focuses primarily on the relationship between attending physicians’ workload and time for teaching, it also signals a need for the academic medicine community to pay greater attention to attending physicians’ workload and well-being as we continue to redesign our care delivery and clinical training models in response to ongoing changes in duty hours regulations. Attending physicians are the backbone of university departments, and they play a critical role in contributing to the advancement of the clinical, educational, and research missions of the academic medical center. Thus, the importance of their contribution to both learners and patients cannot be overlooked.
1. New York State Committee on Emergency Services. Final Report of the New York State Ad Hoc Advisory Committee on Emergency Services. 1987 Albany, New York New York State Health Department
2. Bell BM. Resident duty hour reform and mortality in hospitalized patients. JAMA. 2007;298:2865–2866
3. National Research Council. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. 2009 Washington, DC National Academies Press
5. Roshetsky LM, Coltri A, Flores A, et al. No time for teaching? Inpatient attending physicians’ workload and teaching before and after the implementation of the 2003 duty hours regulations. Acad Med. 2013;88:1293–1298
6. Bismilla Z, Breakey VR, Swales J, et al. Prospective evaluation of residents on call: Before and after duty-hour reduction. Pediatrics. 2011;127:1080–1087
7. Jamal MH, Rousseau MC, Hanna WC, Doi SA, Meterissian S, Snell L. Effect of the ACGME duty hours restrictions on surgical residents and faculty: A systematic review. Acad Med. 2011;86:34–42
8. Williams ES, Manwell LB, Konrad TR, Linzer M. The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: Results from the MEMO study. Health Care Manage Rev. 2007;32:203–212
9. Volpp KG, Rosen AK, Rosenbaum PR, et al. Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. JAMA. 2007;298:984–992
10. Volpp KG, Rosen AK, Rosenbaum PR, et al. Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. JAMA. 2007;298:975–983
11. Desai SV, Feldman L, Brown L, et al. Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: A randomized trial. JAMA Intern Med. 2013;173:649–655
12. Sen S, Kranzler HR, Didwania AK, et al. Effects of the 2011 duty hour reforms on interns and their patients: A prospective longitudinal cohort study. JAMA Intern Med. 2013;173:657–662
13. Farnan JM, Burger A, Boonyasai RT, et al.SGIM Housestaff Oversight Subcommittee. Survey of overnight academic hospitalist supervision of trainees. J Hosp Med. 2012;7:521–523