Organization of Work for Residents — General Medicine Inpatient Services at Three Hospitals
The daily schedules for residents at Franklin, Lark, and Able Memorial largely depend on their year in the program, hospital, and rotation, but includes a mix of patient care and formal didactics. The labor of patient care involves all of the work that must be done when patients are admitted to the hospital: taking a history and performing a physical exam, formulating a diagnosis, coming up with a treatment plan, putting in medical orders (blood work, laboratory tests, imaging studies, administration of medication, dietary needs, physical therapy, etc.), doing procedures (lumbar puncture, placing a central line, etc.) and writing notes that document all of the above for the medical record. Residents work together in teams to provide patient care. First year residents, known as interns, have the most intense schedule and shoulder the largest share of the labor. They are supervised by a senior (second or third year) resident and confer with the attending physician at rounds each day, and occasionally by phone or in informal interactions throughout the day.
The workflow at each program depends on how new patient admissions are assigned to residents. The flow at the Franklin program is different from that at Lark and Able Memorial because of the way the schedule is organized ( and ).
Intern Work Week – Q4 Call System at Franklin, 2008
Intern Work Week – No Overnight Call System at Lark and Able Memorial Hospital, 2009-2010
At Franklin, new admissions are assigned to residents every fourth day, when their teams are “on call.” A team is made up of one senior resident, two interns and two medical students. The interns accept primary responsibility for the team's patients while the senior resident supervises, assists with tasks as needed and conducts informal teaching. At the time of our observations, each intern was permitted to carry up to 12 patients at a time, for a cap of 24 per team.3
During their “call day” teams admit new patients up to 9:30pm or until they reach 24 total patients. These patients become the intern's primary responsibility, as are the still-hospitalized patients admitted from prior calls. The senior resident stays at the hospital until 10:00pm, at which point the interns provide care for the team's patients overnight.
As a result of duty-hour regulations, the program has implemented a “night float” system. The night float resident comes to the hospital in the evening and is responsible for admitting patients that arrive between 9:30pm–8:00am. Interns “inherit” the patient that the night float admitted and become responsible for their care. To comply with duty-hour regulations, interns are required to leave the hospital by 1:00pm on their “post call” day. Their senior resident provides care for the team's patients after 1:00pm.
In addition to admitting new patients, interns, while on call, are responsible for “cross coverage.” When cross covering, residents are responsible not only for their patients but also the patients of the other residents rotating on their service. For example, on the general medicine ward at Franklin VA, there are four teams of residents caring for patients. Each night, three of the teams go home and “hand off” or “sign out” the responsibility for their patients to the on-call team. Each intern becomes responsible for up to 30 “cross-cover” patients in addition to their mix of newly and previously admitted patients. When on call, interns cover as many as 40 patients.
Lark and Able Memorial have a similar structure and schedule with the exception of overnight call. Teams are made up of one senior resident, one intern and two medical students. Residents do not take overnight calls. Teams can get newly admitted patients at any time during their workday (7:00am–5:00/6:00pm). At Able Memorial, interns are paged when a new patient comes in and go to the emergency department to perform the initial admission examination. At Lark, teams do not perform the initial admission examination. Instead, there is a senior resident (known as the 4555 resident because of their pager number) who works in the emergency room performing the admission work up and assigning patients to teams on the general medical floor. At both programs there is a dedicated team of night float residents who accept admissions and cross-cover overnight.
Cross coverage is a major part of the organization of work at all three programs. The transfer of responsibility for a patient marks the beginning and end of each workday. Residents “sign out,” communicating information necessary for care of patients to the team assuming responsibility. The formal transfer of responsibility for patients between teams or to a night float is a major change in the social organization of work since the classic studies of resident socialization (Miller 1970
). Today's residents must leave the hospital at a certain time and are faced with the challenge of knowing what work to hand over and how to communicate it. This feature of the training environment structures how residents understand and enact efficiency.
The Nature of Time
The residents we observed and interviewed at all three programs felt overwhelmed with their workload and did not feel that time was something they could control. That residents are overwhelmed does not represent a change in the experience of training. What has changed is the pace of work. The residents in our study were responsible for approximately the same number of patients as residents of an earlier era — 12–14 — yet are expected to care for them in a shorter amount of time in a crowded technological environment that is more tightly controlled by formal organizational protocols.3
The interaction of these factors makes the workday feel frenzied and unpredictable for residents. For example, an excerpt from our Lark Hospital fieldnotes:
It is 2:53pm and we are rounding with the team. Sally (second year) gets a page, groans and says “it's 4555.” She finds a phone to return the page. When it becomes clear that the team is going to get a new admission the attending Dr. D says to me “this is a major new source of stress for residents. The workload is so intense and the unpredictability and uncertainty of the admissions system makes planning work and carrying it out very challenging. It wasn't like this when I was training — we were at least protected from admissions some of the time.”
The nature of work on an inpatient general medicine ward makes it very hard to transition from what a resident is doing at one moment to something completely different at the next, especially if it is non-emergent and unrelated to patient care. This includes attending morning report, arriving at rounds on time, eating, using the bathroom, and leaving the hospital on time. For example, these Franklin residents struggled with leaving even though they knew that not doing so by 1:00pm violated duty-hour rules:
I'm at the bay with Sarah [second year resident] and Peter [first year]. It is 2:00pm. They are working on getting their sign-outs in order so they can go home. Sarah is on the phone with someone who asks her if she is still at work “I'm trying not to be here, but yes, I'm here.”
To cope with the unpredictable workflow, accomplish required tasks, and comply with the constraints imposed by duty-hour regulations, residents prioritize efficiency.
Training for Efficiency
In what follows we describe aspects of a culture of efficiency that we observed in three residency programs. We did not observe variation in an overarching emphasis on efficiency or in its operational definition: the ability to prioritize, to anticipate problems, and to take action in order to accomplish tasks. While it is possible that this lack of variation is due to the limitations of our data, we believe it is more likely that efficiency is a group norm. The residents we observed exhibited a strong peer and group orientation. Being efficient in residency is no longer simply an individual skill of self-presentation whose mastery signals one's competence. We observed a considerable degree of cooperation among residents in all three programs around managing work.
That physicians in training exhibit a group orientation toward work is not a new finding – Becker et al. (1961)
describe the importance in medical school of making sure that any one student does not increase the workload that all must bear (218) and of avoiding being seen as “goldbricking” (298). Both Miller (1970)
and Mizrahi describe “sloughing behavior, that is sloppy or lazy management of patients… so that it [becomes] the responsibility of another fellow house officer to complete or rectify” as “an imposition on a colleague and, as such, an unforgivable social sin” (1986: 89).
What conflict we did observe among residents around workload was unrelated to sloughing behavior. Instead, spending too much time with patients or taking too much time to accomplish tasks became an issue for contestation. An example from our Franklin fieldnotes stands out:
Around noon, in the resident workroom: a senior resident, Beth, asks her intern Matt if he has finished his work. He says, “Yes, I'm done, just working on these discharge instructions. Beth says, “You need to leave if you are ready to sign out. You are post call. I can take over for you.” Matt protests, “I'm almost done, I can finish!” Beth, her voice raised, says, “You need to learn to LET GO!”
We observed that a major topic of the teaching and practical wisdom passed down from resident to intern concerned the style in which they should work. Residents were critical of interns when they spent too much time with patients:
Peter, a Franklin intern, is seeing his patients. After we finish, the husband of a patient approaches him and says that his wife cannot swallow her potassium pill. He asks Peter to consult the pharmacy to explore how she can get her potassium in a more tolerable formula. We are interrupted by a call from Sarah, Peter's senior resident, who tells him to come up to the ninth floor immediately. Assuming an emergency, Peter excuses himself and we run upstairs. We find Sarah casually leaning against the bay; there is no emergency. She tells Peter that the urgent call was a ruse. She heard he was “being tortured” by the husband of Mrs. X. She tells Peter that he is “too empathic” and to increase his efficiency he can't spend time dealing with every little complaint.
Sarah's criticism of Peter for being “too empathic” is reminiscent of the process involved in “training for detached concern” (Fox 1988
; Lief and Fox 1963
) except that now emotional detachment is a tool of efficiency — being emotionally invested in a patient takes too much time.
While we did observe that residents tried to avoid spending too much time with patients and families, they did not adopt an oppositional, angry attitude like Mizrahi's residents (1986
). One Franklin senior resident reflected on the challenges of reprimanding a junior colleague who spent too much time working:
I had this intern, an excellent physician…he could be my doctor any day. He would break duty hours left and right and I was his senior resident, so I was freaking out, because I'm always trying to get people home at noon…he'd be two hours over. But what was he doing? He was calling their primary care doctors, making sure they knew what happened to their patient…he would call the family members, the kind of things that people want doctors to do for them, he did them all… This was not a lazy person who was wasting time…I had to speak to [program director] about it and I said “people call him inefficient. It's really because he is doing what we all should be doing but there was not time to do it.”
Throughout the summer at Franklin we observed new interns struggle with the tension between needing to be efficient and wanting to be thorough.
We also observed residents reflecting on their own performance in terms of how efficiently they worked. Much of this reflection took on a self-critical tone. We observed the following at Lark Hospital:
We are sitting in the resident workroom at a bank of computers. Sally, the second year resident that I am shadowing says out loud and unprompted as she types notes in the computer, “I find it hard to step back as a second year. I feel like I am a better intern than second year” (note: it is six months into Sally's junior year). Her intern, Neil laughs and says, “that is because you are too thorough.” Sally continues, “I guess I have a hard time letting go…” She says that in the second year she should be focusing on “stepping back” and thinking about patient problems from a level above day-to-day management. She says, “I am worried that by focusing so much on the details of the everyday I might be missing the forest for the trees.”
Much of Sally's self-evaluation reflects on the operational meaning of efficiency, which we found to have greater social salience than previous studies of medical residents suggested.
Residents have a more nuanced understanding of what it means to be efficient than simply providing a concise patient presentation at rounds or turfing patients to other services. During interviews, we probed residents for their operational definitions of efficiency. For our informants, efficiency involves prioritization, the anticipation of problems, and taking action to accomplish tasks. Residents identify the ability to prioritize the always multiple and competing demands on their time as a key part of being efficient. A Franklin chief resident explains:
There are so many competing tasks in a limited amount of time, that when we say efficiency what we mean, or what we often take as a surrogate of that is prioritization and so, if you address every task and every call and every page equally you could get nothing done. So efficiency is being able to say, “This is important now, I finish this now. This is a sick patient I need to deal with now. Taking the social history on this patient and finishing the note can take the back burner. So, it's the ability to dispense your time, which is limited, appropriately… If you don't prioritize and you don't give more time to more important things and less time to less important things then you'll never get anything done.
One third year Franklin resident reflects on the meaning of efficiency:
You start realizing that what efficiency is, is making sure you pay the right amount of attention for the right degree of severity…learning the sick versus not sick. And knowing who you really have to pay attention to, or red flags, or warning signs….
This explanation highlights the other component of efficiency than a resident is required to master: anticipation.
We observed that much of the informal teaching surrounding the pathophysiology of hospitalized patients is concerned with predicting and preventing emergent situations. One Franklin senior resident impresses the following on her two interns during an informal lesson late one night on call:
She stresses the importance of paying attention to urine and fecal retention. Patients who are unable to urinate become a “major problem and quickly.” She recounts a story of a patient who couldn't urinate for 30+ hours. The nursing staff couldn't get a foley (catheter) in him and he started to crump (become acutely unwell). Eventually, they had to call a urologist who performed a surgical procedure. She says that the patient recovered completely after he was able to void and that urine retention, a common cause of crumping, is to be avoided.
We observed that residents communicate the importance of anticipation by using various code words. The phrase “to crump” signals rapid deterioration in a patient (Coombs et al. 1993
). Residents at all three programs discussed “sick” versus “not sick” patients. When we first heard this term used in the context of a routine sign out (“is anybody on your list sick?” was a common question asked by the resident coming on duty), we were confused. Wasn't everyone in the hospital sick? We came to learn that “sick” was a code word for “might crump any minute.” A “sick” patient became an object of heightened attention and concern. “Sick” is a linguistic red flag that allows residents to anticipate and prioritize tasks in the face of limited time.
Residents found resuscitation situations highly stressful and attempted to stave them off by keeping attuned to subtle changes in a “sick” patient's vital signs and proactively managing cardiopulmonary distress, or by being alert to signs that an otherwise stable patient might “crump.” Avoiding emergent situations has become an important external quality metric. “Failure to rescue” patients with unexpected clinical deterioration is receiving increased attention as a measure of the quality of care (Silber et al. 2007
). During our time observing at Lark hospital, a young patient with sickle cell disease developed worsening acute chest syndrome overnight that remained unidentified until he went into cardiopulmonary arrest. He was successfully transferred to the ICU and survived.
This incident occurred on the first day and sense-making (Weick et al. 2005
) around this event reverberated through our time there. Sally, the junior resident caring for the patient, was especially distraught. From our fieldnotes:
Sally and her attending, Dr. D, talk about what happened. Sally says she feels very badly about what happened and that it is her fault. Dr. D reassures her that she did everything that she could. Dr. D asks Sally how she signed out the patient with sickle cell disease to the night float. She asks, “Did you use the word ‘sick’ to describe him? Because sometimes that alerts the person getting sign out to pay extra close attention to the patient.” Sally says, “Well, I didn't really think he was sick last night. He had been noncompliant with his oxygen all day so I assumed his breathing trouble was related to that.” She tells Dr. D that the only thing she signed out on this patient was that if he were to develop a fever the night float should do a pan culture. She says she ordered a chest X-ray before she left and put it on the list of things to do overnight, but she didn't stress it. The night float did not follow up on the results overnight, as the patient got progressively worse.
Being efficient is both a social norm and a strategy that residents employ to cope with a workload whose accomplishment in the time allotted is uncertain.
Systemic Threats to Efficiency
When coding our fieldnotes we found that residents at each of the three programs would use the term “systems problem” to explain why they have difficulty being efficient. From our analysis of those utterances we found that “the system” is a catchall term that encompasses a variety of features of organizational life. Instead of developing an oppositional attitude to patients (Mizrahi 1986
), residents conceptualize “the system” as an entity that works against them in their efforts to prioritize and anticipate. Through an analysis of those places where the system caused problems for residents and how they handled them, we can see how physicians in training are socialized to think about the pressures of working in a complex organization, and how system problems become accepted, taken for granted and seen as par for the course in the provision of care (Dixon-Woods 2010
; Waring 2007
People are components of the system — the consultant physician who takes hours to call back, the nurse who does not record vital signs consistently or the social worker who refuses to put in a request for a patient to be discharged to a nursing home — threaten efficiency. Technology is also part of the system — the unfamiliar blood pressure machine whose operation is opaque, the broken electronic informed consent machines that delay completion of procedures, and the printer that will not print sign-out sheets, delaying a timely exit — all of these frustrate residents' best efforts to act efficiently.
New communication technologies like cell phones are a feature of the system that challenges the enactment of efficiency (even though they are often heralded as efficiency-promoting [Wu et al. 2010
]). Residents at Franklin and Able Memorial carry program-issued cell phones that they are required to answer regardless of what they are doing. Administrative rules prohibit residents from setting up voicemail accounts.
During our observations at Franklin and Able Memorial, cell phones rang constantly. They interrupted formal didactics; attending rounds; physical exams; procedures; conversations with patients, their families, nurses and ancillary staff; sign-outs; and casual conversations between residents. For example, the Franklin program has an educational conference for residents from noon-1:00pm three times a week. When we observed at these conferences, we noted each time any attendee's phone rang. We attended 19 noon conferences and observed an average of 10 phone calls per conference, with a high of 20 and a low of 6. In one report, the same intern was called six times. A similar event was observed at Able Memorial when the resident we were shadowing was called out of a small lecture on diabetic ketoacidosis nine times. These data are not systematic and we cannot say for sure how generalizable they are. However, it is instructive to compare the frequency of phone calls we observed to the average frequency of pages per hour found in a 1988 study of internal medicine residents: one (Katz and Schroeder
Handoffs were also very vulnerable to being interrupted by cell phone calls, as this Franklin fieldnote suggests:
I am in the tiny call room with Jen, an intern. She is on call and getting sign-out from Alice, an intern. We sit on the bottom bunk bed as Alice briefs us on the patients and the things that need to get done. As Alice is talking she is interrupted by three phone calls. The first from her senior resident with a question, the second from a nurse wanting an order put in (which Alice does quickly on the computer in the room, “before I forget”), and the third from the ophthalmology fellow following up on one of her patients. The fellow wants Alice to order intravitreal antibiotics [medication injected directly into the eye] and he wants them “STAT to the bedside.” Alice hangs up and rolls her eyes sarcastically, “what a perfect call. STAT intravitreous antibiotics. The pharmacy is totally going to get on my case about this.” She tells Jen she will be back to finish up the handoff later, because she has to go manage this situation. She does eventually complete the handoff about an hour later.
Hospital handoffs have received steadily increasing regulatory and research attention in the last five years (Cohen and Hilligoss 2010
). There is a push to standardize handoffs to reduce the likelihood of non- or miscommunication of patient data (Starmer et al. 2012
). Our observations suggest that future research and policy-making should take into account the vulnerabilities that arise due to the environment in which the handoff occurs.
Franklin and Able Memorial residents had mixed opinions about cell phones. Some liked that they cut down on the “phone tag” required by pagers, while others felt that they interfered with prioritization and anticipation. The presence of cell phones encouraged the nesting of tasks within time, as the field note excerpt above illustrates. Nesting occurred when a resident working on a task was interrupted by a cell phone call requesting her to do another task, which she must decide to attend to at that moment or at a later point. Tasks accumulate over time. Nesting contributes to the intensity of the workload and is a major threat to efficiency because keeping situational and attentional focus becomes problematic as the number of tasks multiplies. Nesting is not merely a matter of interruption, it is also a matter of tasks that require different levels of attention and action arising rapidly and unexpectedly.
The spatial and socio-temporal rhythms of the hospital as a complex organization are another barrier to the efficiency that residents strive to achieve. Examples that we observed include: the code call that demands an immediate response, received while seeing patients in another building three blocks away that cannot be reached by the normal route because access is blocked by new construction; the STAT CT scan that cannot be ordered on a holiday weekend or the phlebotomy team that refuses to draw blood on a patient if called after 4:30pm, even though they are supposed to be on call until 5:00pm.
Residents at Lark and Able Memorial both identified the way the hospital assigned new admissions to teams () and the night float cross-coverage model as problematic aspects of “the system.” These challenges, all of which we observed or were told were a “systems problem,” highlight why residents often express uncertainty about whether they are able to achieve what is expected of them in the time required. The residents in our study still train for uncertainty (Fox 1957
), but the uncertainty that they must learn to manage primarily arises from the process of moving patients through a fragmented and complex health care system, rather than from epistemic quandaries.
The poor meshing of multiple interacting systems has been identified as a major contributor to medical error in the Human Factors approach to improving patient safety (Peters and Peters 2007
). Systems discourse is the main way hospital policies concerning adverse events are organized and communicated. Residents in our study use systems language to describe the problems that come from working in a complex healthcare organization, as well as for making sense of specific incidents (Waring 2007
). Tom, an intern, describes the challenges of working efficiently at Franklin:
I think it's mainly in the hospital settings that knowing who to call is the big issue for my efficiency. I don't know all the right numbers to call. I don't know who's the right person to contact if I need to get something done. I still struggle with that because… I'm not sure why I still struggle with it. I've been there for a while now. But I think this hospital is so big and it's such a lumbering beast…there's so many people making decisions that it's hard to figure out who to call. That's a systems problem and not an intern problem.
By suggesting that his confusion over whom to call is a systems problem and not an intern problem, Tom locates interns outside of and against “the system.”
This kind of oppositional thinking toward the challenges posed by the system permeates the culture of efficiency we observed. The latent message here is that while physicians must work within the system, they are not a part of it. As a result, residents do not feel responsible for enacting change within the system. Instead, they attempt to maneuver within the constraints that the system presents.
Linda, a Franklin medical student, expressed the futility of trying to change the system during a discussion of a near miss on rounds: “as an individual you feel very futile with these system level errors. I'm only here for a few weeks, what can I do?” This feature of the residency experience encourages the development of a “learned tolerance” of systems problems that leads to the acceptance of adverse events as normal, natural troubles of providing inpatient care (Dixon-Woods et al. 2009
; Waring 2007
In order to cope with systemic threats to efficiency residents learn to master workarounds to problems caused by “the system.” A basic example from our Franklin fieldnotes concerns the acquisition of supplies for a patient:
I see Nate (an intern) come into the resident room with two opened packages of chux (absorbent pads), which he puts in his locker. He says, “I'm stealing these for one of my patients who needs them.” Anne (an intern), who is sitting at a computer, says “you know you can go through outpatient meds for that.” Nate says “yeah, but I'm not going to go through that.”
In this case “going through with that” involves logging on to a computer to place a formal order; for Nate pilfering from the supply room takes less time and ensures the chux are available when needed.
Other workarounds concerned the problems encountered when trying to communicate with consultants from other departments. Residents employed a number of strategies to get consultants to call back more quickly:
I am sitting in the workroom with Lana, an intern and Eric, her senior resident. Lana has been on hold for 10 minutes. She needs to get a cardiology consult to prescribe one of her patients a specific medication. She is having a hard time getting a return call and needs an answer sooner rather than later. Eric tells her to ask them to write a quick note authorizing the medication. He explains that this will get them down here faster because they won't write the note without doing the consult. Lana says “oh, clever!”
While these workarounds on the surface seem to be short cuts that residents take to get their work done, we argue instead that they represent teachable moments in which lessons about accountability, the feasibility of system improvement and professional identity are imparted.