What are some of the impacts of the Duty Hour Restrictions on Residency Training?

A new study was published in BMJ online this week (1) about the impact of work hour reform. The authors, Dr. Chaiyachati and colleagues performed a time-motion observation of internal medicine residents at six residency programs that were a part of the iCompare group (Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education).

Eighty interns were observed by 23 trained observers. They began recording the residents’ activities as soon as they arrived at the hospital. They stopped collecting data when the intern finished their shift. The residents’ time was divided into activities and coded into seven major categories (4 Required: Education, Rounds, Work, & Handoffs AND 3 Other Applicable: Direct Patient Care, Indirect Patient Care, & Miscellaneous). Residents were observed between May 10, 2016 and May 31, 2016 for 94 weekday shifts and a total of 2173 hours. 

The authors found that residents worked a mean of 10.5 hours per shift (9.6 to 12.5 hours).  Overnight call shifts were 20.9 hours long (16.7 to 26.7 hours). Indirect patient care was the most frequently observed activity across all 6-hour time periods in the day. Direct and Indirect patient care was often seen in multitasking. More than half of the time recorded by the observers included residents multitasking other activities with indirect patient care. More than 10 hours of a 24 hour period was spent interacting with the electronic medical record.

At AMEE 2019 in Vienna, I went to a session in the Postgraduate Training (Residency) tract.  The session was led by Dr David Gachoud and colleagues at the Lausanne University Hospital in Lausanne Switzerland (2). His team had originally used the time and motion study technique in 2015 to evaluate Internal Medicine residents’ time usage.  One of their findings was that residents switched tasks on average 15 times per minute. One outcome of this study was to work with their residents to improve the schedule, specifically to increase the amount of time that was available to prepare for morning rounds by delaying the start of rounds by one hour every morning. They also hired some new secretarial staff to relieve the administrative burden of the residents. 

In this study, they recorded 63 day shifts between May and July 2018.  What they found was a little surprising: ward rounding duration was decreased by 25 minutes and time allocated to direct patient contact went down by 18 minutes.  The percentage of rounding time remained at about 50 percent between the two studies (2015 to 2018).

So, two really interesting studies of time and motion in internal medicine residency programs. This seems to be a time-intensive but really useful method to look at work hours. And more importantly the actual work that is being done by residents during their shifts.   

References

(1)   ​Jena AB, Newhouse RL, Farid M, Blumenthal D, Bhattacharya J. Association of residency work hour reform with long term quality and costs of care of US physicians: observational study.  BMJ 2019; 366: 14134 (Published online 10 July 2019)

(2)   Gachoud D, Monti M, Marques-Vidal P, Kraege V, Aebischer O, Garnier A. Impact of Increased Preparation Time for Residents Before Ward Rounds: The MED2DAY study. AMEE 2019  Short Communications #4R4. August 26, 2019 Vienna Austria.

AMEE 2019 Update

AMEE 2019 UPDATE

I was excited to get to attend and present at the Annual Conference of the AMEE which is the Association for Medical Education in Europe. AMEE is a worldwide organization with members in 90 countries on five continents. AMEE promotes international excellence in education in the health professions across the continuum of undergraduate, postgraduate and continuing education. We have been going to AMEE for several years because of the outstanding plenaries, the energy of the participants, and the high quality and diversity of the presentations.

Since I am almost wholly absorbed in Residency Education at this point in my career, I tried to make sure to hit as many of the session on Postgraduate Education as possible. The Europeans (and most of the rest of the world) call Residency training as the postgraduate period. It makes sense, they go to medical school (undergraduate) then graduate from medical school and have further “postgraduate” training.  This year, AMEE had a track for Postgraduate sessions.  I attended almost all of them and I wanted to highlight a few of my observations.

1) International but similar problems—I saw presentations from the Netherlands, the United Kingdom, Thailand, Australia, the United States, Taiwan, Canada, Japan, Singapore, Denmark, Switzerland, Scotland, Argentina, Colombia, and New Zealand. That is mind boggling.  All these were talks just about residency training.  And everyone is grappling with similar issues such as resident well-being, burnout, quality of feedback, teaching a safety culture, curricula, and faculty development.  It is a little reassuring and a little depressing.

2) Resident well-being is an international issue—I thought it was interesting that so many different counties and cultures have this problem. Residents are overworked and underpaid.  They are underappreciated everywhere. One internal medicine program in the Switzerland rearranged their entire rounding schedule to try and address issues of lack of teaching time and administrative burden for the inpatient rounding teams. A pediatrics program created a new resident organization to address the burnout and disaffection that came to their department after increasing stress and a resident suicide attempt. An Internal Medicine program in Singapore created an Escape room orientation game to build teamwork and interdependence.

3) Challenges in the residency curriculum are not the ACGME’s fault—every country and program and specialty has challenges.  Many of the programs had developed amazing and unique ways of addressing their curricular hurdles. A program in Canada was working on a pilot program to help the resident inpatient teams to come to a shared understanding of the purpose of the patient’s hospital admission.  I thought this program was particularly interesting as we have seen delays in treatment and discharges because of the shift-based teams that care for a patient. Twice daily attending changes can cause all kinds of disruptions.  A surgical program in the UK found that their program was put on notice for their poor performance on a national residency survey. They spent the next six years working on the educational environment, support for teachers, and improving the learning conditions in order to address their deficiencies.

4) Simulation is important but it doesn’t solve every problem.  A great talk by a young educator from Scotland looked at the deficiencies of teaching with Simulation. He had several great findings. For one, the simulations no matter how realistic never had the heavy weight of an actual clinical situation. Residents always know that they will eventually find out what the answer is in a simulation not so much in real life.  Another finding was that simulations are always done during the workday, but the most challenging clinical situations always happen to a resident at night or on the weekend.  Every good story from my residency training period begins with “one night when I was on call at ….”

All in all, this was another outstanding AMEE conference. Vienna is a great city to visit and we got to learn about another Subway / Metro system.  It was great to see old friends from England, Brasil, St Maarten, St Kitts, Scotland, the Netherlands, and elsewhere.  Also was nice to see Professor Ronald Harden, the General Secretary of AMEE. Also met several new friends from the US, Austria, Canada, Trinidad & Tobago, and Thailand.  If you are a medical educator, I would highly recommend this meeting as a place to learn and meet new colleagues from around the world.