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.