Residency work hour limits: a little time off, a lot to consider.

The culture of graduate medical education is changing. Over the last decade, forces both inside and outside the medical community have initiated a re-examination of how this country trains physicians. One area that has received significant attention is the extended work hours historically experienced by medical residents. In June of 2002 the Accreditation Council for Graduate Medical Education (ACGME) instituted work hour limitations for all resident training programs. There are three main components to these new rules: 1) limiting the work week to 80 hours, 2) limiting continuous time on duty to 24 hours (with 6 additional hours to complete all tasks) and 3) requiring 24 consecutive hours off out of every 7 days. The future will likely involve even further restrictions. Federal legislation is pending that would impose stricter limitations on work hours, transfer enforcement from a private agency (ACGME) to the Department of Health and Human Services and impose significant fines for violations. The state of New York has already passed laws limiting resident work hours, and other states are considering similar legislation. Work hour restrictions are not unique to this country, either. In 2004 the European Union enacted laws that by 2009 will limit all physicians, residents included, to a 48-hour work week.

Adapting to these changes has not been easy for many residency training programs. Coinciding with often increasing patient loads, the reduction in residency work hours has forced programs to create novel ways to schedule patient coverage. One tool increasingly being utilized is the "float" rotation, in which a designated individual will cover one or more services and allow the primary resident team to have scheduled time free of patient responsibility. While float systems do aid in compliance with work hour rules, their ultimate effect on resident education and patient care is unknown. In this issue of the Southern Medical Journal, Wallach et al (1) report on the prevalence of float systems in internal medicine residencies around the country and the methods used to evaluate resident performance. Their findings confirm the increasing usage of float systems by residency programs, and reveal a lack of consistency by which residents are being evaluated during these rotations.

While this study is a good first step in analyzing float systems, there must be further research into the effects of work hour limitations as a whole. The benefits of a well-rested physician may seem obvious; however, there are potential ramifications associated with work hour reductions that need to be considered. What is the true effect on physician quality? Work hour limitations are not a reality for physicians who have completed training. An argument can be made that it is better for residents to learn how to practice medicine in a realistic environment (including sleep deprivation) while they have added oversight and supervision. Is society willing to accept fundamental changes in the physician-patient relationship? While people may have concern and empathy for the strains (ie, long resident work hours) placed on the medical profession as a whole, attitudes can quickly change when the situation becomes personal (ie, "what do you mean my doctor is not available?"). What will be the financial burden? If training hours are reduced, then just maintaining the current level of patient care and physician quality could necessitate increasing the length of residency training as well as the number of medical residents. This would represent a major financial burden to an already strained healthcare system. What will be the effect on resident attitudes and mindset? There are concerns that younger physicians are not as committed to their patients or the practice of medicine as in years past. While some may pass this off as the inevitable nostalgia of a passing age, many of us currently involved in training residents have experienced enough of these attitude changes on a personal level to merit the possibility of a larger trend. For a profession so grounded in self-sacrifice and service to others, this is a topic that deserves serious consideration.

The question of how best to train physicians has never been more complicated. The ultimate goal remains clear--do what is best in terms of patient care. Deciding the proper balance required to achieve this goal is the challenge for today's physician-educators. As changes continue to unfold, they must be accompanied by rigorous analysis and honest debate. There will be costs associated with any changes to resident education, no matter how well intentioned. Let us make sure we can afford them.

Reference

1. Wallach S, Alam K, Diaz N, et al. How do internal medicine residency programs evaluate their resident float experiences? South Med J 2006;99:919-923.

Charles M. Edwards, MD, MBA, and Denise Edwards, MD

From University of South Florida College of Medicine, Tampa, FL.

Reprint requests to Charles M. Edwards, MD, MBA, University of South Florida College of Medicine, 12901 Bruce B. Downs Boulevard, Tampa, FL 33612. Email: [e-mail]

Accepted March 1, 2006.