Work-hour restrictions affect emotional health, job satisfaction, education

The negative effects of work-hour limitation may counter the benefits for residents.

A group of recent studies have examined the effects of work-hour restrictions on residency training.

Researchers at the University of Colorado Health Science Center surveyed residents before and one year after work-hour restrictions were put in place. They found that while burnout continues to be a significant problem for internal medicine residents, restricting hours may affect education and residents’ satisfaction with their programs.

The University of Washington Affiliated Hospitals Internal Medicine Program, sent surveys to residents in 2003 and compared to similar surveys from two years earlier. Most residents in the more recent survey reported that work-hour restrictions had a positive effect on well-being; they demonstrated an increase in career satisfaction and a decrease in emotional exhaustion.

A third study surveyed residents at Massachusetts General Hospital and Brigham and Women’s Hospital regarding their experiences with adverse events; excessive work hours were one of the most common reasons for mistakes cited by residents.

The studies were published in the Archives of Internal Medicine.

Educational impact

“The new 80-hour work restriction has trade-offs,” said Ravi Gopal, MD, assistant professor of medicine at the University of Colorado Health Science Center. “It decreases the amount of resident burnout, particularly emotional exhaustion. Depression also seems to improve. But the educational impact may be negative, with residents sacrificing attending educational lectures to get their work done.”

For this prospective, longitudinal evaluation, Gopal and his colleagues twice surveyed University of Colorado Health Science Center internal medicine residents who participated in the study (139 total) — once in May 2003 before work-hour restrictions were enacted and once a year later.

The surveys measured burnout using a number of scales: the Maslach Burnout Inventory, the Cognitive Hardiness Scale and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire.

The Maslach Burnout Inventory contains 22 scaled questions on emotional exhaustion (9 questions), depersonalization (5 questions) and reduced sense of personal accomplishment (8 questions).

The researchers defined burnout as high scores in either emotional exhaustion or depersonalization categories; high burnout was defined as high scores in both categories.

The Cognitive Hardiness Scale includes 30 scaled questions regarding attitudes and beliefs about work, life, commitment, challenge and control. A score higher than 59 identifies those who may not be vulverable to burnout.

The Primary Care Evaluation of Mental Disorders Patient Health Questionnaire screens for mental disorders and includes a subset of two questions on depression.

Source: Arch Intern Med

Education and attendance

Eighty-seven percent (121) of the residents responded to the surveys in 2003; 74% responded in 2004.

Average hardiness scores were higher in 2004 (55.2 vs. 57.2). Other trends included diminished depersonalization (61% vs 55%), burnout (74% vs. 58%) and high burnout (36% vs. 25%; P=.05).

The researchers found a 13% reduction in emotional exhaustion in the second survey (P=.03); however, average attendance at educational conferences dropped from about 18.99 per month to 15.56 per month (P=.01).

“Only time will tell if this is an equal trade-off,” Gopal told Endocrine Today. “If residents are able to self-educate by reading medical literature and applying it to their patients, then it’s a reasonable trade-off.”

Residents attended two fewer morning report conferences per month in 2004 (P=.02). Residents in 2004 reported that they read medical topics more often, however, with 54% reading more than two hours per week vs. 42% doing so in 2003 (P=.06).

Overall satisfaction with the residency program decreased in residents that worked under the old system as well, from 76.3 mm to 70.3 mm on a 100-mm visual analog scale (P=.02).

“[This] is due to the fact that since the amount of work is unchanged in the entire internal medicine program and interns who previously performed the majority of that work are now limited, the upper-level residents are having to work harder than previous upper level residents,” Gopal said.

“They worked hard as interns and are not getting the ‘pay-off’ as upper-level [residents]. Also, human nature does not like change,” he said.

Better solutions may exist, but they would depend on the problem being solved, according to Gopal.

“If the problem is resident exhaustion, there is no other solution. If it’s patient safety, there are many system interventions described that could help. If it’s resident education, there are no hard data looking at the effect on medical residents’ knowledge or skills,” he said.

High compliance marks second year of ACGME duty-hour standards

Two years after the Accreditation Council for Graduate Medical Education common duty-hour standards took effect, the majority of residency programs are complying, according to a confidential Internet survey of more than 50,000 residents. Programs are using innovative approaches to restructure duty-hour schedules for residents. In addition to questions on duty hours, the resident survey included questions on other important aspects of the resident learning environment, including resident supervision, their perceptions on their education, and the amount of noneducational work residents perform. The ACGME gathered data on duty-hour compliance from program directors for all 8,038 accredited programs during academic year 2004-05. ACGME field staff also interviewed approximately 12,000 residents during 1,851 program site visits; program directors and faculty were interviewed during site visits. In 2005, 33,204 residents were surveyed in 1,954 residency programs. The response rate was 89%. Combined with the residents surveyed last year, the ACGME has gathered information on compliance with duty-hour standards from 58,380 residents – more than half of all residents in ACGME-accredited programs. The survey data for this year indicate that 997 residents (3% of respondents) reported working more than 80 hours a week during the previous four weeks, compared with 3.3% of respondents last year. Of the 2,002 programs that were reviewed during the academic year, 7.3% received citations related to duty-hour noncompliance. The ACGME issued 195 duty-hour citations; 31 were for violations of the 80 hours per week limit, 31 for violations of the 24-hours-plus six-continuous duty hour limit, 19 for violations of the 10-hour minimum rest period, and the rest for a variety of other violations. During the academic year the ACGME received 16 resident complaints for duty-hour violations, compared with 53 complaints the previous year. The ACGME duty-hour standards went into effect July 1, 2003, for all ACGME-accredited programs. The standards include an 80-hour a week duty-hour limit, averaged over four weeks; at least one day in seven free of clinical and educational activities; call limited to no more than once every three nights; and continuous time on duty restricted to 24 hours plus six additional hours for patient hand-offs and paperwork. The ACGME has created the Committee on Innovation in the Learning Environment, which will analyze and make recommendations on various aspects of residents’ educational environment, including duty hours, work flow, and innovations in curriculum and teaching methods. For more information, visit www.acgme.org

Satisfaction with careers

“The implementation of the Accreditation Council for Graduate Medical Education work-hour limitations represents a profound change in the structure of resident education,” wrote researchers from the division of pulmonary and critical care medicine and the department of internal medicine at the University of Washington, the Seattle Veterans Affairs Puget Sound Health Care System and the Seattle Cancer Care Alliance.

In this study, an 85-item survey was sent to residents in early 2004. The survey included questions on the effects of work-hour restrictions on patient care, resident education and resident well-being; questions on well-being included career satisfaction, depression and burnout measures that were identical to surveys sent in 2001.

Burnout was measured using the Maslach Burnout Inventory.

Seventy-three percent (118 out of 161) of residents responded to the surveys. Eighty-four percent reported a positive effect on well-being as a result of work-hour restrictions.

Emotional exhaustion was reported by fewer residents in 2004 vs. 2001 (40% vs. 53%; P=.05), and on an emotional exhaustion subscale, average scores were lower in 2004 (24 vs. 26.4; P=.05).

No differences were found for depersonalization or sense of personal accomplishment.

Residents in 2004 reported an increase in happiness with their careers (80% vs. 66%); there were almost twice as many residents in a “very happy” subset (33% vs. 18%; P=.01).

More residents (37%) reported a negative effect of work-hour restrictions than reported positive (29%) or neutral (34%) effects. Forty-seven percent reported thinking that they could take better care of patients than cross-covering physicians could, but they were forced to go home because of the restrictions.

Regarding education, more (47%) residents reported a negative effect than reported positive (32%) or neutral (21%) effects. Educational conferences were the most frequently missed or cut-short activities; 81% reported missing or cutting educational activities short at least twice monthly.

Forty-five percent of residents reported missing or cutting short their rounds at least twice a month; 27% reported doing so weekly.

“Our findings suggest partial success, with most residents reporting that they approach patient care with more energy, and the plurality agreeing that work-hour limitations make medical errors less likely,” the researchers wrote.

“However, many residents also reported negative consequences of the work-hour limitations, such as frequently needing to cut corners in patient care ... these negeative effects may to some extent mitigate the benefits of the work-hour limitations,” they wrote.

Reporting on adverse events

Reshma Jagsi, MD, DPhil, resident physician in radiation oncology at Massachusetts General Hospital, and her colleagues administered a questionnaire in June 2003 to all residents and fellows at Massachusetts General Hospital and Brigham and Women’s Hospital.

The questionnaire contained items on patient safety, work hours and fatigue. Residents were asked to report on adverse events, mistakes and near-misses; questions on adverse event severity, prolongation of hospital stay, whether the adverse event was due to a mistake or not, and the level of resident responsibility for this mistake were included.

Other questions asked the postgraduate year of the resident, the specialty, setting of rotation, patient load and work hours.

The response rate was 57% (821 responses); only 689 respondents in a primarily clinical year of training were included in the analysis.

Fifty-five percent (321 residents) reported having cared for a patient with an adverse event. The most common events reported were procedural complications (31%), adverse drug events (21%) and infections (11%). Adverse drug events were reported as due to mistakes in 36% of cases.

The varying degrees of severity reported for adverse events were fatal (8%), life-threatening (15%), significant but not life-threatening (47%) and insignificant (29%). An adverse event that had prolonged a patient’s stay was reported by 132 residents.

Ninety (24%) of those who reported adverse events thought the events was caused by a mistake; 77% of these believed they were partially responsible. A list of potential causes for mistakes was given for the residents to check off; of these, 19% thought that working too many hours could be a cause.

“By showing a correlation between self-assessed fatigue and errors in a broad spectrum of specialties and settings outside the intensive care unit, our findings add to the evidence from other recent studies that have suggested that long hours of traditional rotations lead to increased errors compared with schedules limiting work hours,” Jagsi said.

However, Jagsi said, several factors other than resident work hours were also perceived to contribute to errors in teaching hospitals, including inadequate supervision and problems with handoffs. Both causes were as frequently cited as resident work hours.

“Policies focusing exclusively on resident work hours may fail to produce substantial improvements in patient safety. Rather, varied measures, targeting the multiple areas of potential systems-level failures identified by front-line providers, must be undertaken to improve safety,” she told Endocrine Today. “Moreover, resident work hour limits should be carefully implemented to avoid adversely affecting work intensity or continuity.”

Ensuring adequate supervision and continuity of care is particularly challenging in the context of efforts to reduce resident work hours, according to Jagsi.

“Policies limiting resident work hours were motivated in large part by concerns about the impact of fatigue upon the quality of care,” she said. “Resident physicians are front-line providers of medical care with a unique vantage point from which to comment upon patient safety events.”

“Our results support the perception that adverse events are commonly encountered by physicians and often associated with errors. The results also offer insights into the nature and causation of adverse events and errors in teaching hospitals, suggesting that causes are multifactorial and a variety of measures are necessary to improve safety,” Jagsi said.

Resident work-hour limitations may fail to produce substantial improvements in patient safety if they are implemented in ways that result in reduced supervision or continuity.

“Medical educators must be particularly vigilant to implement reductions in work hours in ways that minimize adverse effects upon resident supervision and continuity of care,” Jagsi said.

“Setting the work restriction at 80-hours was an arbitrary decision not based on science; something had to be done to improve medical residents’ working conditions,” Gopal said.

“The ACGME took a bold step that has forced programs to adapt. This transition is continuing as programs restructure the resident’s clinical responsibilities and educational activities. We will have to continue to study the effect of the change to determine the next effect on residents, patients, and the health care system as a whole,” he said. – by Evan Young

For more information:

• Gopal R, Glasheen JJ, Miyoshi TJ, Prochazka AV. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005;165:2595-2600.
• Goitein L, Shanafelt TD, Wipf JE, et al. The effects of work-hour limitations on resident well-being, patient care, and education in an internal medicine residency program. Arch Intern Med. 2005;165:2601-2606.
• Reshma Jagsi R, Kitch BT, Weinstein DF, et al. Residents Report on adverse events and their causes. Arch Intern Med. 2005;165:2607-2613.