There is mounting evidence that the current ACGME work hour limitations have led to some unintended consequences for residency training. Our findings suggest that whereas house staff perceive work hour limitations as having some positive effects on their well-being, they struggle to complete patient care responsibilities and teaching duties within the restricted hours.
Evaluating the impact of program changes is crucial to improving residency training. We developed scales to measure house staff perceptions of the impact of work hour limitations on several aspects of residency training. These metrics were developed in stepwise fashion, beginning with focus groups to identify issues important to house staff regarding work hour limitations, building survey items to characterize these issues, and finally using factor analysis to identify the underlying domains. This approach ensured that we assessed the areas of residency training that house staff felt were most affected by work hour limitations, increasing the validity of our findings.
House staff perceived negative effects of work hour limitations on their clinical experience. Senior residents, in particular, felt that the pressure to comply with work hour limits led to decreased thoroughness of workups and delays in patient care, which adversely affected their satisfaction with the level of care they provided. Furthermore, house staff reported direct patient care and teaching duties as the main reasons for noncompliance, suggesting that the workload for house staff may be too heavy for the current permitted work hours. A previous review of house staff work activities found that house staff spend up to 35% of their time on activities of marginal or no educational value.10
Transfer of these tasks to other providers is often proposed as a solution11–13
; however, shifting excess work from house staff is potentially very expensive, with estimates in the hundreds of millions to billions of dollars.14–16
As there is little additional funding to offset these costs, it may be difficult for hospitals to afford these changes. In addition, programs must carefully implement workload reduction to ensure that the patient care and educational experiences required for residents to become competent physicians are not compromised.
House staff in our survey reported that they felt compliance with work hour limitations may have adversely affected patient care and safety. This is consistent with other studies, which have also shown the possibility of an increased risk of adverse events with work hour limits, primarily because of fragmentation in patient care.17,18
Furthermore, inadequate supervision and problems with transfer of care between physicians may be as important as excessive work hours in causing mistakes.19
Our data, together with previous studies, suggest that any decrease in errors resulting from decreased fatigue may be at least partially offset by delays in patient care, discontinuity of care, and communication issues. Objective data are needed to determine whether the negative effects perceived by house staff have in fact affected patient outcomes.
Satisfaction with training is in part driven by satisfaction with the learning environment. Factors enhancing learning, such as contact with the attending physician, patient rounds, and seminars, are positively correlated with satisfaction with internship, whereas factors contributing to perceived mistreatment, including sleep deprivation, are negatively correlated.20
Although house staff at the study institution were moderately satisfied with their training program in the setting of work hour limitations, the scores for the education questions for this scale were lower than those for questions about job satisfaction. This difference may indicate that any gains in job satisfaction made by decreasing sleep deprivation may be offset by disappointment caused by fewer learning opportunities.
Perceptions regarding the impact of work hour limitations varied by year of training. Senior residents were more likely to perceive problems with clinical experiences and patient care and safety, and to be less satisfied with indicators of resident well-being. These differences may reflect discontent with how the work hour limitations were implemented, frustration with a mid-residency change, or dissatisfaction with having to assume an increased share of the work previously done by interns. Conversely, senior residents have increased experience and responsibility, which may lead to a better understanding of the impact of work hour limitations on patient care and education, both of which may ultimately affect satisfaction with training. Follow-up studies are needed to determine whether the difference in perception between residents and interns will persist beyond the period of transition to the new system.
Compliance with work hour limitations in this study was poor. Although Internal Medicine programs had guidelines specifying an 80-hour work week and 1 day off per week before mandatory ACGME rules went into effect, the 30 consecutive hour and 10-hour limits were new. House staff were least compliant with these 2 rules, likely because patient care rarely followed such a rigid schedule. Whereas most violations were minor, over 40% of house staff had violations of greater than 60 minutes. Thus, attempting to comply with the limitations may be an additional stressor that could offset gains in resident well-being.
There was a high response rate to the survey, making it more likely that the opinions expressed in the survey are representative of the Internal Medicine house staff at the study institution. In addition, we were able to capture the sentiments of house staff who made the transition from 1 system to another, capturing valuable insight into the benefits and shortcomings of both systems. Although our findings are consistent with those seen in surveys from other disciplines,21–23
this was a single center study of Internal Medicine house staff at an academic medical center during a period of transition, which may limit its generalizability. Although we are not aware of any other concurrent significant changes in the hospital and residency program environments during the study period, such changes would affect house staff experiences and confound our results. Additionally, we relied on self-report to assess behaviors, a limitation of survey methodology. Other studies have demonstrated that self-report overestimates compliance with desired behaviors,24,25
suggesting that our findings may underestimate the impact of the limitations on those behaviors. We measured resident perceptions, not direct patient care or educational outcomes. These self-perceptions are subject to bias, particularly with senior residents, who were likely affected by prior experiences. Finally, difficulties with compliance, which may reflect local program structure, may have affected house staff attitudes toward the limitations.
Improvement in patient care and safety and in the education and well-being of house staff are the ultimate goals of changing the system of residency training. Our study indicates that the current ACGME work hour limitations have complex and perhaps unintended consequences on the residency training system, and demonstrates the need for ongoing evaluation to assess the impact of program changes on residency training.