Hospital as permanent habitat may have been the norm for the first residents, but today's trainees and hospitalists are battling for balance. For them, scheduling means far more than personal druthers; it's a matter of safety and quality—with patient care, physician well-being, and resident learning on the line.
Over the past 30 years, hospital life has changed dramatically, from the advent and adjustments of resident work hours to the birth and boom of hospital medicine. Before restricted work hours, trainees worked under less supervision, with no ancillary services and less advanced medical treatments, caring for many patients who could now be treated outside the hospital, said Mark A. Levine, MD, FACP, associate dean for graduate medical education and professor of medicine at the University of Vermont College of Medicine in Burlington.
“In my day, we were also the IV technicians, we were also the phlebotomists, we were involved in patient transport, and those are tasks that we would never push on a resident at this point in time,” said Dr. Levine, who is an ACP Regent and Chair of ACP's Education and Publication Committee. “Nowadays, we really believe that if residents are going to spend all these hours in the hospital, they better be learning all that time, and they better be doing tasks that are appropriate for the education they've received.”
Hospitalists have also seen their schedules shift, and the initial default of seven on/seven off appears to be falling somewhat out of favor, with flexible schedules increasing in popularity. All the while, residents' schedules are incongruous with those of practicing hospitalists, said Thomas G. Cooney, MD, MACP, a professor of medicine and vice chair for education of the department of medicine at Oregon Health & Science University in Portland and Chair of ACP's Board of Governors.
Most recently, in March, the Accreditation Council for Graduate Medical Education (ACGME) finalized work-hour rules for the 2017-2018 academic year that lift the 16-hour work limit for interns and allow all residents to work up to 28 continuous hours, among other provisions.
Paging Dr. Zombie
Flashing back to the era before the first work-hour restrictions, unlimited work pushed physicians in training well beyond comfort, Dr. Cooney said. “I describe myself at the end of a six-month stretch of every other or every third night working 110 hours a week and often being up for 30 consecutive hours as a zombie,” he said. “And I'm actually one of the people who does well with relatively little sleep.”
For Dr. Levine, hours in the hospital were endless. “You would hope that the day after you were on call (and call was every third [night]) that you could get out on time to go home for dinner, but there were times that even that day after being on call, you were there very late.”
The ill effects of sleep deprivation on physicians are well established in the literature. For instance, residents who regularly work 24-hour shifts make 36% more serious medical errors than those whose work is limited to 16 hours and double their risk of an accident on the drive home after 24 hours of work, according to a 2007 report by The Joint Commission.
Despite the dangers, sleep deprivation was a staple of the unregulated residency environment, Dr. Cooney said. “There's no question we made errors...that we probably would not have made if we weren't so exhausted,” he said.
Susan T. Hingle, MD, FACP, Chair of ACP's Board of Regents, recalled a particular awful call night (her second as an intern), when she admitted 14 patients on top of the 10 she already had. Afterward, while she was driving on no sleep for 36 hours, her car was rear-ended and needed to be towed, and someone snatched her purse from her as she walked back from the service station.
“But I didn't quit. That was the mentality: You just sort of sucked it up. This was what you signed on to do, and being a doctor is important,” Dr. Hingle said. “And by the time you start residency, you've got all your medical school debt, so what are you going to do? You've got to get through it.”
In 1988, the ACGME specified the first restrictive standards for all residency programs: one day in seven away from the hospital, on-call duty in the hospital no more often than every third night, adequate backup in case resident fatigue jeopardized patient care, and policies in place to ensure adequate supervision of trainees. Since then standards have tightened, culminating in the ACGME's 2011 work-hour requirements, which limited clinical and educational work to 16 hours for interns and 24 hours for other residents (plus no more than four hours to manage transitions in care).
The 16-hour limit for interns is absent from the new requirements, which add that residents must have at least 14 hours free of clinical work and education after 24 hours of in-house call.
As part of ACP's writing group that provided feedback to the ACGME on the new policy, Dr. Levine said one lingering issue is that the one day off in seven is averaged over four weeks. “We were very concerned that, if left to be too flexible, people could work 24 days in a row without time off,” he said. “Unfortunately, there is a very small number of programs that could abuse their residents and try to overwork them.”
The solution proposed by the ACP group specified that residents should have two days off in any 14-day period. Overall, ACP supports removing the 16-hour rule and mandating 14 hours free of resident work after 24 hours on call in the hospital.
The ACGME requirements also state that working from home (e.g., using an EHR, taking calls) must be included in the 80-hour weekly work limit. ACP agrees with this change in principle, but experts expressed concerns about enforcement.
Residents log in from home all the time, even on their days off, said gastroenterology fellow Lavanya Viswanathan, MD, FACP, MS, immediate past Chair of ACP's Council of Resident/Fellow Members. “I think in theory it's a good idea [to count those hours] because I think it's prudent to recognize that doctors are working even if we're not in the hospital,” she said. “But I'm not sure how feasible it'll be to actually capture those hours.”
Typically, the honor system is used to report hours, said Dr. Cooney, who is wary of the prospect of systematically capturing hours worked at home (by tracking use of the EHR, for instance). From an educational point of view, writing a discharge summary from home is different work than, say, logging in to see what a consulting service said about a patient. “We don't want to discourage the latter; it's the former that we're concerned about,” he said.
The significance of seven
From residency to practice, seven is an important number. Night-float residents often come in to the hospital at 7 p.m. and, if all goes well, leave after morning rounds around 7 a.m. And, of course, hospitalist schedules are famous for seven days on duty followed by seven days off duty.
One of the fathers of hospital medicine, Robert M. Wachter, MD, FACP, memorably called the sweeping practice of seven on/seven off “a mistake” at Hospital Medicine 2016. Hospitalist demographics have changed over time, with doctors practicing at all stages of life—not just in their 30s and 40s, said Dr. Wachter, chair of the department of medicine at the University of California, San Francisco. “I don't believe this is a viable schedule for a 60-year-old,” he said.
About 38% of hospitalist groups serving adults only reported using seven on/seven off as the predominant scheduling pattern in the Society of Hospital Medicine's 2016 State of Hospital Medicine report. That figure was about 42% in the 2012 report, the first to pose the scheduling question.
Furthermore, about 31% of groups in the 2016 report said they use Monday through Friday schedules with rotating or moonlighter coverage on weekends, and about 10% use other fixed rotating-block schedules (e.g., five on/five off). Back in 2012, groups reporting Monday through Friday schedules and other block schedules were in the gross minority, with about 42% of groups reporting variable or other schedules (this figure was about 21% in the 2016 report).
At Beth Israel Deaconess Medical Center in Boston, the hospitalist schedule is inherently flexible and built with every attempt to accommodate scheduling requests, said hospitalist Evan Gwyn, MD, assistant director of administration for the hospitalist group, which is spread over four sites. The preference of seven on/seven off seems to vary by experience, he said.
“Most of our new hospitalists tend to do seven on/seven off when on the nonteaching services. I think that's the expected default,” said Dr. Gwyn. “Most new hospitalists just out of residency don't have other nonclinical responsibilities which would require a different schedule pattern.” Experienced hospitalists with more nonclinical duties tend to find it easier to work three or four days straight and take care of administrative jobs on other days, he said.
The health system has started to transition from a Monday through Sunday to Saturday through Friday model for its seven on/seven off schedules, Dr. Gwyn said. “We find that it's better tolerated. In a traditional Monday through Sunday schedule, Mondays tend to be quite difficult, tasking providers with mid-morning multidisciplinary rounds and disposition decisions on a census of patients who are entirely new to them,” he said. In contrast, the weekends tend to be a little slower and give hospitalists two days to familiarize themselves with the patients, get comfortable with disposition planning, and be ready to make complex transitions come Monday morning, said Dr. Gwyn.
In terms of time in the hospital, most hospitalist groups serving only adults reported a duration of scheduled shifts between 12 and 13.9 hours for both day (about 69%) and night shifts (79%), according to the 2016 State of Hospital Medicine report. Only about 1% and 4% reported 14 hours or more in the hospital for scheduled day or night shifts, respectively.
To this point, Dr. Cooney maintained that the external practice environment does not have hospitalists working 16-hour shifts, so he's not convinced there is a need for internal medicine residents to work more than 16 hours at a time. “I would personally be fine if we were limited to 16 hours—period,” he said.