Residents' Work-Hour Restrictions Shift Burden to Faculty Members

ROCHESTER, Minn., July 24 -- The old guard in medical education who predicted that shortened work hours for residents would lead to shoddy training of young physicians are claiming vindication.

Aside from a concession that young doctors may be better-rested, a survey of 111 key clinical faculty members at 39 internal medicine residency programs found the reduced working hours, imposed by the Accreditation Council for Graduate Medical Education, had led to a sorrier state of affairs for the residents as well as members of the teaching faculty.

The faculty members perceived a worsening in residents' continuity of care and the physician-patient relationship, and a decline in both residents' education and professionalism and accountability to patients. A majority of faculty members felt the ability to place patient needs above self-interests had declined.

About half the faculty members thought residents' well-being had improved, reported Darcy A. Reed, M.D., M.P.H. of the Mayo College of Medicine here, and colleagues at Johns Hopkins, in the July 23 issue of Archives of Internal Medicine.

As to their own well-being, with residents off resting, many faculty members felt they spent more time providing inpatient services. They also noted decreased satisfaction with teaching, the ability to develop relationships with residents, and overall career satisfaction.

The dissatisfaction was greatest for those who had spent more years teaching, they said. Faculty members who spent at least five years teaching were almost three times more likely to say that the reduced resident hours had an negative impact (OR 2.84; 95% CI, 1.15-7.00).

In May 2005 -- a year after implementation of ACGME duty-hour limits -- surveys were sent to 154 key clinical faculty and 111 responded. Three-fourths of the responders said they had at least five years of teaching experience.

The ACGME duty hour limits included a maximum 80-hour workweek, a minimum of 10 hours between shifts, and a 24-hour maximum on continuous duty as the primary decision maker for new patients.

Among the findings:

• Eighty-seven percent of the faculty member reported worsening in the continuity of care given by residents (P <0.001).
• Two-thirds said residents' communication with patients and families decreased (P <0.001).
• Sixty percent said overall patient care worsened with the shorter resident work hours (P <0.001).
• Just over half (51%) said residents professionalism had suffered and 57% said residents' ability to put patients' needs above self-interests had worsened (P <0.001).
• Eight-five percent said residents were less fatigued, and about half of the faculty said they were seeing less resident burnout (P <0.001).
• Forty-seven percent said they were now spending more time on patient care, and 40% said they had less time for mentoring residents (P <0.001).
• Fifty-six percent said they had less satisfaction with teaching since the resident work hour limits and 33% aid they had a decrease in overall career satisfaction (P <0.001).

Dr. Reed noted that the primary purpose of residency training is education and on the basis of the survey responses "certain aspects of residents' education may be compromised."

But the authors pointed out that the faculty perceptions may have been colored by the fact that they were trained "in an era without limitations on duty hours."

The authors said the study was limited by its observational design and by fact that study participants were limited to clinical faculty at residency programs affiliated with medical schools. Their experience, they wrote, may not reflect the views of faculty at community-based residency programs. Moreover, the authors did not evaluate the degree of compliance with limits on duty hours at any of the 39 programs.

Barbara Schuster, M.D., of Wright State University in Dayton, wrote in an editorial that the resident work-hour restrictions "have improved the well-being of residents but may be worsening the well-being of faculty members."

More study is needed to determine the best way to educate physicians so that they can deliver "safe, responsible, patient-center, quality health care," said Dr. Schuster.

"In the meantime, transferring responsibility to faculty may lead to faculty burnout and dissatisfaction," she concluded.