As I listened to my attending explain how during her residency training she was on call every third night, I realized how the definition of “call” had significantly changed since that time. For her, it meant her shift started at 6 a.m. and ended at 8 p.m. the next day, totaling the shift to upwards of 36 hours. My call, on the other hand, was a mere 6 a.m. to 8 a.m. within the same day. I could understand why she laughed, saying, “Oh, how things have changed.”
Before 1989, there were no duty-hour restrictions for medical residents. It was a time when working 100-plus hour weeks was normal, and even expected. However, following the tragic case of Libby Zion, the Bell Commission passed the first duty-hour restrictions in the country: limiting residents working in New York City hospitals to work 80 hours per week.
The Accreditation Council for Graduate Medical Education (ACGME) followed suit, albeit over a decade later, in 2003 applying these restrictions to all medical residencies in the country and restricting shifts to a maximum of 30 hours. Furthermore, in 2011, they limited the length of shifts for interns to 16 hours, which brought the duty-hour debate back on the table.
Program directors across the country began to respond that such shift restrictions reduced the quality of training, inhibited professional maturation, and increased hand-offs without improving patient safety or the quality of care. Several studies demonstrated such findings, however, none were wide-spread, randomized control trials until the iCOMPARE study was created.
This study randomized 63 internal medicine programs throughout the United States to either a flexible duty-hour schedule or a standardized duty-hour schedule. Flexible schedules had no restrictions on intern- or resident-shift limits. However, both groups were subject to 80-hours-per-week limits.
The researchers hypothesized that interns in the flexible group would spend more time on direct patient care, they would have greater satisfaction with their educational experience and would have non-inferior standardized test score. Moreover, that faculty at flexible programs would also be more satisfied with the educational experience.
The results revealed that interns in the flexible group did not spend more time than the interns in the standard group on patient care. Shockingly, both groups spent only roughly 13 percent of their shift in direct patient care. However, this should come to no surprise for current residents. Besides the two to five minutes pre-rounding and few minutes of rounding with each patient, rarely do we spend more time directly talking to the patient or their families unless there are questions later in the day. As the study notes, a majority of the time — greater than 60 percent — is spent on indirect patient care such as chart checking, writing notes or calling consults.
Furthermore, the rates of burnout on the Maslach Burnout Inventory were horrifyingly greater than 70 percent in both groups. This is consistent with recent studies examining burnout and moral injury. However, it begs the question of whether duty hours are a significant contributing factor to burnout? Or rather, could it be the dismal 13 percent of residents’ time spent directly with the patient?
Results from the intern surveys revealed how there was a two- to three-fold increase in dissatisfaction with work-life balance for interns in the flexible groups as compared to the standard group. Interns responded that the flexible duty hours had a significantly negative effect on job satisfaction, morale, time with family and friends, time for hobbies, health and overall well-being. It also had negative effects on the ability to attend educational conferences, teach medical students and participate in research.
In contrast, surveys of program directors underscore their dissatisfaction with the standard programs. Specifically, interns’ ownership of patients, resident morale with the learning environment, time for feedback and adequacy for bedside teaching.
The discrepancy between residents and program directors might be due to a difference in priorities. Interns are focused on completing all the necessary tasks for the day, with shorter shifts making it more difficult. In contrast, program directors are focused on providing a robust teaching environment that can develop further under a flexible program. One thing is clear: the flexible programs have a significant impact on interns’ work-life balance.
Two subsequent studies came out from the iCOMPARE trial. First, demonstrating that patient safety outcomes are not significantly different between both groups. Second,sleep and alertness is also not significantly different between both groups.
With flexible groups having non-inferior test scores on standardized tests — no change in patient safety outcomes and no change in sleep and alertness — is there truly a difference if interns are restricted to 16-hour shifts? It seems that the only difference is intern perspective on how these shifts affect their work-life balance.
A resident wrote for NPR underscoring how longer shifts were previously shown to have negative effects on empathy. He shared an experience in the ICU when he had a patient admitted on the brink of death a couple of hours before the end of his shift. Sadly, the gravity of the patient’s condition was not the focus of his thoughts; rather, it was the amount of paperwork this last admission had added. Most physicians can agree that our empathy towards patients is far from ideal after being awake for 28 hours.
Some may argue that the current generation’s focus on work-life balance is idealistic and unrealistic in the field of medicine. However, with medicine changing rapidly with continual advancements in technology, our prior methods for structuring workflow are not sustainable. The 36-hour shifts that my attending used to work can no longer function in a system where patient turn-over is higher, documentation load is larger and patients are sicker.
We must listen to our residents on the front lines and make a change to better the lives of future physicians. Otherwise, we risk missing a critical opportunity to adapt.
Michael Grzeskowiak is an internal medicine resident.
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