The results of our study support the perception that duty-hour regulations have increased attending clinical responsibility and decreased teaching time, leading to the perception of a more intense ward attending experience and work environment. Attending physicians perceive a shift in responsibilities from the traditional teaching role to a clinical and managerial role and have less time to accomplish other activities. They note a greater opportunity to observe learners process information in “real time” and that while there is less time for teaching, teaching efforts are more concise and targeted. They describe less time to work with inexperienced members of the team, especially medical students.
Learners have experienced multiple changes with the implementation of duty-hour regulations. Key perceived losses include time for question asking, synthesis, autonomy, and reflection on patient care. The “divide and conquer” approach to patient care results in the perception of efficient but disjointed rounds and compromised team cohesion. Compromised continuity of care and the consequential missed learning opportunities, particularly in the postcall period, are additional concerns raised by residents and faculty. Finally, our learners and attending physicians perceive a change in the meaning of professionalism.
Medical education has evolved from a system supporting maximal independence with minimal attending contact to one with fully engaged attendings who directly participate in patient care. This increased involvement may not necessarily translate into improved teaching and learning. In a recently published study conducted following duty-hour implementation, 70% of residents believed there was not enough time for teaching by attending physicians13
and 57% reported rounds were focused more on getting work done than on teaching. Defining the balance of time spent discussing management versus teaching and the optimal use of educational rounding time is critical to reexamine in the new era. Medical students pose a particular challenge as traditional presentation formats and time for data synthesis are curtailed. While 1 study supports that duty-hour reform has had minimal impact on medical student activities and on their perception of education14
the impact of duty-hour regulations on medical student education and learning is largely unknown and will be challenging to assess.
Our attending physicians describe using more concise and targeted teaching methods to adapt to time pressures that may result in improved overall teaching effectiveness15
and better fit the attention span of learners. Duty-hour regulations coupled with increased patient acuity and shortened length of stay1
add time pressure to inpatient teaching that is long described in the outpatient environment. Effective and efficient teaching strategies used in the outpatient setting may extrapolate well to the inpatient environment.15–18
Thus, defining how doctors teach and learn best in compressed time is key to improving our educational efforts within duty-hour regulations.19
What number and intensity of patient encounters is enough for adequate internal medicine training? Patients are the key curricular content. Before duty-hour regulations, many residents worked over 100 h/wk and now average 80 h/wk. Therefore, residents spend approximately 20% less time caring for patients. One way to accomplish this reduction is to decrease patient numbers, but will residents achieve sufficient competence in inpatient care? It has been argued that internal medicine residents have an excess of exposure to inpatient medicine, thus this reduction may be of little consequence. As a solution to maintain patient numbers, programs may hire nonphysician practitioners to assist in work and enhance efficiency. Responses from faculty at our national workshop highlighted that while these services helped they only partially offset the challenges of working in compressed time.
In the preduty-hour era, increased attending presence was found to result in improved learning with maintained autonomy.20
In the postduty-hour era, many of our residents suggest autonomy has decreased. Perhaps the active role-attending physicians have in directly managing patients is the primary reason. It remains unclear whether duty-hour regulations have taken us below the optimal level of autonomy needed for learning. As autonomy remains a valued component of the training curriculum, attending physicians need to pay particular attention to balancing their level of involvement while giving residents sufficient room to exercise independent decision making. Determining the appropriate level of autonomy and identifying methods that attendings can use to foster autonomy is a rich area for future study.
Duty-hour regulations have also challenged the traditional definition of professionalism. Historically, professionalism emphasized tireless commitment to patient care and working regardless of time and fatigue. This behavior was expected and rewarded. Professionalism has evolved to include the importance of adequate rest and time away from patient care to create a workforce more receptive to learning and less likely to make medical errors. As elements of these 2 messages collide, our learners and attendings feel conflicted about how best to uphold the principles of professionalism when duty-hours have elapsed and critical work has not been completed. An attending physician trained under the traditional model may view a resident who complies with duty-hours as “unprofessional.” As we obtain more data on the impact of duty-hour regulations on patient care outcomes, medical errors, and patient satisfaction, and become more skilled at patient care transitions, we will have a clearer understanding of the impact of duty-hours on professionalism.
In the new era, our attending physicians are experiencing a perceived work hour expansion, which will continue unless other changes are made to offset the load. Longer hours may lead to decreased professional satisfaction, diminished academic productivity and promote burnout, potentially making internal medicine seem less attractive to trainees.21
Duty-hour regulations have highlighted the specific skill set needed to be successful as an inpatient attending physicians. Our data suggest that attending physicians who are efficient, deliver focused, clinically relevant teaching, provide timely feedback and easily move between providing direct patient care and supervising care are highly valued in the new era. Adaptability appears critical to success. While these attributes have always been valued, there are increasingly important in today's work environment. Additionally, it remains challenging to measure the influence of the increasing number of teaching hospitalists, many who are recent graduates, who are potentially less vested in other professional activities, and may have more time to be “hands on” in the inpatient environment.
There are several limitations to our study. First, our data are derived from attending physicians and residents in 1 residency program and cannot be directly extrapolated to other programs. Second, the authors who ran the focus group sessions and coded the responses are both inpatient attendings with their own experiences and perceptions of the impact of duty-hours on teaching. We attempted to minimize these 2 potential biases by soliciting input from participants at regional and national workshops on this topic. Feedback from participants suggested our themes are common to many university-based residency programs. Third, our resident e-mail survey response rate was low. Therefore, we presented our resident survey results at a house staff meeting where themes were validated and expanded upon. Fourth, confounding variables may affect the perception of increased work intensity, including shortened patient length or stay and increased patient acuity. Finally, as our study is qualitative, we are indirectly measuring changes in work intensity for attending physicians. These perceptions are potentially impacted by inherent struggles associated with adapting to major change.
Duty-hour regulations encourage us to determine what is essential to preserve in the attending-learner interaction and be proactive and reflective in adapting the existing model of inpatient medical education. We need to reexamine appropriate patient volumes, methods to maintain autonomy, and enhance professionalism. Additionally, the increased role attending physicians play in direct patient care and the consequence of this on their personal and professional lives are areas for close monitoring. To our knowledge, this is the first study assessing attending physicians' experiences teaching internal medicine residents in the era of duty-hour regulations. Continued efforts to explore the impact of duty-hour regulations on the lives of attending physicians and their learners are needed so that we can understand the implications on physician work satisfaction, burnout, and resident preparedness for practice.