Blog | Monday, June 4, 2012

QD: News Every Day--One year later, work hour limits didn't improve residents' work-life balance

The latest Common Program Requirements for Resident Duty Hours and Supervision were implemented in July 2011 with misgivings and mixed feelings among interns, residents and program directors.

To understand how concerns about work-life balance and the quality of medical education and patient care have played out in the past year, researchers (a team that included Staci Fischer, MD, FACP) conducted a follow-up national survey of residents. The perspective piece appeared May 30 at the New England Journal of Medicine.

All 682 sponsoring institutions of accredited U.S. residency programs were invited to participate in the survey. 123 institutions in 41 states agreed to participate, comprising 26,581 residents across the specialties. 6,202 individual responses (23.3%) were collected.

The questionnaire focused on the perceived effects of the 2011 regulations on the care of patients and residents' education, quality of life, and supervision. A majority of respondents (77.6%) were in their first 3 postgraduate years and in training programs in internal medicine (21.8%), family medicine (14.9%), or pediatrics (10.8%). Demographic and specialty distribution paralleled national numbers.

Although twice as many residents reported receiving better supervision as reported receiving worse supervision (17.9% vs. 8.3%), the availability of supervision was overwhelmingly thought to be unchanged (73.8%). The perspective authors noted, "This finding is interesting, given that interns are now required to have 'immediately available' supervision, an important policy change necessitating the presence of a senior resident or attending physician within the hospital at all times."

Although 42.8% of residents reported no change in the quality of education, a nearly equal proportion (40.9%) reported worse education, while 16.3% saw improvement. Just over half (51.5%) of residents believed that preparation for more senior roles was worse. The authors speculated that the 16-hour-per-day limitation for first-year trainees created the sense that junior-level responsibilities have been shifted to senior residents (65.5%).

"Scheduling changes with increased 'night float' duties may be reducing residents' exposure to patients, availability for educational conferences, and continuity of care--an effect that is also reflected in a marked increase in transitions of care (72.0%)," the authors continued.

While half of residents (50.9%) expected a better quality of life with the new regulations, only interns (61.8%) saw it. Senior residents reported that their quality of life has suffered (49.7%) and residents claimed that their work schedules were worse (43%). Again, just more than half 50.1% of residents said that the amount of rest they got didn't change, and 58.9% said the total number hours they worked didn't change.

The survey results suggest several possible explanations reasons:
--Residents are working the same number of hours with no change in the amount of rest and with worse schedules, reducing their overall quality of life;
--Residents believe that preparedness for their senior residency is being delayed;
--There has been no increase in available supervision, or in safety and education, and
--Handoffs have increased, reducing continuity of care and the educational and emotional benefits of a strong doctor–patient relationship.

"A one-size-fits-all approach may not be adequate or appropriate for all trainees and training programs," the authors concluded. "Ultimately, the intended and actual effects of the 2011 ACGME duty-hours requirements may not be aligned. Nevertheless, more study will be needed to quantify how safety and quality of care, as well as resident education, are being affected."