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Feature Stories BIGChanges A Day in the Life of a Resident Under New Duty-Hours Restrictions By Anita Smith It’s a Sunday on the Trauma Service at UAB’s University Hospital. Fourth-year surgery resident Phillip Lackey, M.D., is a chief resident on the service; he’s on call today, and he’s busy. Arriving at the hospital before 5:30 a.m., Lackey has a junior resident in tow as he makes rounds at trauma patients’ bedsides in intensive care and on floor units. He makes notes and puts in orders for what needs to be done for these patients. ROUNDS IN A RUSH Shortly before 8 a.m., Lackey walks to a conference room in an adjoining building, where Trauma Service Morning Report is about to begin. This morning, 13 people are participating. Using Morning Report time to review the status timetables for various procedures. And they run a tally of available beds. After Morning Report, Lackey joins an attending surgeon and a junior resident for more patient rounds. Summoned frequently by his pager, Lackey answers some patient-care questions by phone and temporarily interrupts rounds to handle other needs in person. He receives word that a truck collision victim is being brought in, and he and an attending surgeon report to the emergency room to lead the assessment, make sure the patient is stabilized, and put in orders for diagnostic scans of his injuries. A few minutes later, Lackey interrupts his rounds again to go to the CT-scan area to reassure the accident victim, who is having trouble lying still for the scan. departure time that precisely. “Back then, we went off-duty whenever our work was done,” he says. The difference between then and now is the “80-hour rule,” a hot topic of discussion in residency programs at the UASOM and across the United States. In effect since July 1, 2003, the rule specifies that all residents must be limited to 80 hours on duty within a seven-day workweek. This includes in-house call and encompasses all overnight-duty hours spent in the hospital, regardless of whether a resident spends some of those hours resting. The 80-hour rule covers all 119 specialties and subspecialties in 7,800 residency programs in the United States that are accredited by the Accreditation Council for Graduate Medical Education (ACGME). of every trauma patient in the hospital, residents and attending physicians go over what has been done for patients thus far, their progress, and what will be done next. They review patients who are victims of everything from car accidents to gunshot wounds. They discuss special issues— such as patients who have been intubated and those dealing with complications such as pneumonia and kidney dysfunction. They identify Yet in all the uncertainty of this busy day, Lackey is aware of something about his own schedule that he would not have known several months previously. “I know it’s very likely I’ll be going off “Our restricted duty hours make it even more important that we as residents become better at communicating with one another about such issues as tests and other care we’re ordering for our patients.… We need to learn how to have better communication.” — Anne B. Davis duty and leaving the hospital this evening between 5 and 6 o’clock,” he says. At that point, he will be expected to hand off in-progress patient-care work to other residents. Prior to mid-summer 2003, Lackey could not have pinpointed his expected JUDGING THE IMPACT One of those dealing with the effects of the hours change is Dennis W. Boulware, M.D., the UASOM’s senior associate dean for education. “This new rule has somewhat polarized the medical community nationally,” says Boulware. “Some greatly welcomed it. Others think it is horrible and that it will contribute to the destruction of the tradition of medicine. My opinion is somewhat mixed.” Boulware says years must pass before the full impact of the 80-hour rule will become clear. However, he has come to some conclusions after a few months of experience with the rule and its consequences. Boulware says the rule came into being because the ACGME was feeling pressure from consumer groups and Congress, fueled by worries that overtired residents were contributing to errors in patient care. 10
Feature Stories Regarding his own concerns about the potential negative impact of the rule, Boulware notes that by reducing residents’ on-duty hours, ACGME has created the need for additional “patient-care handoffs”—residents having to hand off patient-care responsibilities to others. Boulware fears additional handoffs could contribute to lack of continuity in patient care and could result in more confusion in the health-care system. He says this is ironic, since the ACGME was trying to use this new rule to contribute to a smoother system. “I am concerned, too, about what this might mean down the road regarding public trust in a health-care system already under fire by the public,” says Boulware. Regardless of one’s opinion about the 80-hour rule, Boulware says, it’s here to stay—at least for the foreseeable future. “The ACGME planned for this a long time and it has a reputation for sticking to its rules.” Another prediction that the ACGME will hold fast comes from Marshall M. Urist, M.D., vice chair of the Department of Surgery and co-director of the General Surgery Residency Program. “At least where surgery is concerned, I think arguments to the ACGME appealing for exceptions are not going to go very far,” he says. “Although we do know that it will be possible to increase residents’ on-duty hours from 80 to 88 in special cases, we also know such an increase can be made for educational purposes only, not to accommodate service needs.” other care we’re ordering for our patients. This is good in that we need to learn how to have better communication. Some of us tend to be solitary thinkers, and while solitary thinking can have good points, it’s also important to learn to be great team players. After all, most of us will have partners with whom we will be communicating after we go into practice.” Another positive, says Davis, is the injection of some balance into doctors’ lives. “Physicians need to be well-rounded. They don’t need to be trained as individuals who work all the time. These morerestrictive duty hours address that.” Surgery resident Lackey says there is no doubt that his own family life has benefited from the new rules. He has more time with his wife and He is uneasy about the consequences on the structure of residents’ educational experiences. At least until residents become accustomed to the new rule, Boulware says, senior residents often will spend time supplementing what junior residents can do for patients within limited duty hours. In addition, he notes, the new rule poses challenges in scheduling certain educational experiences for residents. Boulware is worried, too, about the long-term impact the duty-hours changes could have on medical-school faculty: “Faculty are being impacted in two ways. Because of fewer resident duty hours, some faculty who once had residents with them now do not. Also, fewer resident duty hours result in additional patient-care responsibilities being shifted to the faculty. I fear that these impacts could drive some faculty out of medical education into private practice, particularly if they already had been considering private practice as an option.” Based on his own observations, Urist questions the validity of linking sleep-deprived residents to errors in patient care. “I have not observed a big problem with residents making bad decisions because they were sleep-deprived,” he says. Urist adds that he had been concerned about whether the new rule would permit surgery residents to take part in the diverse surgery experiences they need, but he says so far that has worked out well. On the positive side, he says the 80-hour rule will free residents to explore outsidethe-hospital learning experiences such as independent reading. MORE TIME, MORE QUESTIONS Residents themselves see some positives about the rule. Anne B. Davis, M.D., a third-year resident in internal medicine, says, “Our restricted duty hours make it even more important that we as residents become better at communicating with one another about such issues as tests and 11 In order to hand off patients at the end of shortened duty hours, residents such as Phillip Lackey must put an even greater emphasis on coordination and communication. two children, and he even can make plans for predictable weekend time off. At the same time, he worries about the impact that restricted duty hours might have on continuity of patient care and on the quality of training that residents receive. He wonders, “Will residents receive less training because the training is less rigorous? Will they have the skills they need to have?” Lackey also ponders possible future implications for residency programs—implications that are topics of debate throughout the medical profession. Will the 80-hour rule set the stage for major changes in the way residents are trained? Will it in fact help set the stage for residencytraining periods that will become even longer than they are today? As Boulware says, “Only time will tell.”
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