The Sept. 2003 issue of the GME E-letter posed the following "Question of the Month:"

“What has been your program's experience with the new duty hour regulations from the Accreditation Council for Graduate Medical Education (ACGME)? How are residents feeling? Attending physicians? What about patients? And the hospital's bottom line?”

Following are the responses received, in chronological order; identifying information has been deleted. The views expressed here are not necessarily endorsed by the AMA.

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For our stand-alone, community-hospital, family practice program, the 80-hour limit has not been difficult to comply with (we were compliant before). The 24 + 6 has been problematic, however (although not necessarily difficult) and has come at some sacrifice in continuity outpatient care, and elective experiences.

The residents spend more time signing in and out and are absolutely neurotic about forgetting to follow up on something and waste 1-2 hours a day with writing notes to each other in an effort to "cover" each other.

The new interns have not figured out what "ownership" is and think in shift mentality. That is the worse disaster of all. They're dragging their feet to whittle away their 6 hours post-call and leaving the work to my poor seniors, who do have a sense of ownership. Also, they've figured out if they come in earlier on a call day, say 4:30 a.m., "to get their am notes all written," their 6 hours are up by 10:30 a.m. the next day, and they leave shortly after morning report. I put a stop to that real quick, but residents are clever creatures: Give them a rule and they'll figure out how to make it work to their advantage.

I have noted delays in care, though nothing critical. Orders that didn't get written in a timely fashion may result in extra hospital days. I do believe there will be a critical decision that gets delayed because someone left and forgot to sign something out. I never saw so much discontinuity!

For family practice, I think the duty hours regulation was unnecessary and adversely affects one of the patient care concepts we hold most dear...continuity.

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We do not have any problem with the 80 hours per week limit. However, we have problems with the 6-hour transition period. Until now, our policy has been that when a first-year resident is on call in the ICU, the Pulmonary/CCM fellow on call for that day stays in-house. In accordance with the new regulations, following an in-house call, our fellows would not be able to take any new patients next morning or stay in house after 2 p.m. Since most of our fellows have other assignments next day (ie, MICU, Pulmonary Consult Service, and outpatient clinic), complying with the new post-call regulations is very difficult.

We would like to know how other programs handle the above problems. We may have to allow the fellow on-call to take calls from home and come to the hospital only when his presence is required.

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Our main problem has been the medical intensive care unit. Residents are on-call for 24 hours, from 7 a.m. to 7 a.m. The problem is with early morning admissions. There is often insufficient time to finish the workup before they must leave the unit at 1 p.m. Some residents feel that they are abandoning the patient at a crucial time, "dumping" on their colleagues when there is still work to do, and depriving themselves of the educational benefit of seeing critical illness in development. Whether patient care may suffer due to lack of continuity is unknown. Our current structure is that our attendings round each morning at 0800 so the entire team benefits from work and teaching rounds every day.

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Our rheumatology program has not had any difficulty meeting the 80-hour limit, but the 4 days off a month has created a lot of suffering among the attendings and fellows. Traditionally, we have carried the pager for a month at a time when on consult service, with the following 2 months completely free of after-hours responsiblity. Both the attendings and 2nd year fellows are used to this schedule and have planned vacation accordingly. We (the fellows) do not consider this a hardship, because call is really not that bad and usually we only have to round 1 day on weekends anyway. But requiring us to have no responsiblities 4 days a month has created a lot of animosity in the department concerning the pager.

The new rules have not improved our lives. Fellows should have the right to request exemption from the rules if they feel that their program's call is reasonable.

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The biggest problem I run into is compliance with the 36-hour shift. Post-call, patients often have many loose ends that need to be addressed to make efficient use of hospital services. There are often unstable patients or those who could potentially go home if the results of their studies are back (which is usually in the afternoon post-call).

The 80-hour limit has not been a problem (except for some interns) due to the averaging over 4 weeks.

Residents are happy to have the protection of the limit and the protected time to rest, but we get frustrated by the post-call limit. The first 12 to 24 hours of admission are crucial for maintaining efficient use of hospital services.

The time taken to produce an effective sign-out on unstable patients could be applied to their workup, but we feel obligated to leave the hospital by the deadline.

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The 80 hours can work, but the 10-hour time off is a disaster for our program. The same sentiment has been stated by every program director I contacted at the recent Association of Program Directors in Internal Medicine meeting. Aside from the strain on programs and the unpopularity even with residents, the break in continuity of care is disconcerting at best, and more likely a threat to the very patient safety it is supposed to augment. This doesn't even take into account the "shift mentality" that this politically engendered rule is bringing about. All of us have already seen this phenomenon evolving.

Even though our esteemed regulators are having a field day and now have created even more reasons to reproduce and metastasize, it is a very dark time for medicine.

In addition, the new rules have created major scheduling challenges, even in a residency where residents were never indispensible to patient care (ie, there is a resident on call only half the time—the rest of the time the faculty have to take call, and the obligations for faculty have simply increased).

Nevertheless, we been very successful in complying and will have to see how it all plays out in terms of resident learning, etc.

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After working with the duty hours regulations for 3 months, we find them to be huge hassle with no real benefit. We always treated our residents humanely, but we did not have to keep track of every hour. Now the residents have to keep continuous logs so that we can verify that we have not had any infractions.

They don't like having to do that. We have had to decrease the clinical contact time for residents, and they feel that they are not getting as much teaching. Our residents never complained about the hours before, but now they complain constantly. They hate the new regulations. The residents knew that there were some rotations that had long hours, but they knew they would learn a lot on those rotations. They then had lighter rotations at other times. Now we have had to water down the really good rotations.

Also, the first year residents cannot be on call very often so the second year residents have to take more call. This decreases the learning of the first years and is not appreciated by the second years. Our first year residents have never been on call more often than every third or fourth night. But now they can be on call only 1 night a week. They run out of their 80 hours, even though they have met all the other criteria. You can't learn as much if you are only admitting patients once a week. And if they are on call, they have to miss noon conference the next day because their 6 hours is up. So now our residents attend fewer teaching conferences.

In my opinion, the problem with the duty hour rules is that they are too specific. There are so many different criteria to meet. It is a scheduling nightmare to meet every criteria all the time.

First, I think the programs that never had any problems should be allowed to function as they always did. Why break what was working? Start applying restrictions only to the programs that weren't treating residents appropriately.

Second, set one general guideline, like the number of hours worked per quarter, or per month. Then let the programs and the residents determine how to do that. Not all residencies operate under the same circumstances. Some are large, some are small. Some are all in one location, some utilize several locations. Some are community based, some are university based. Let us each figure out the details of what works for us.

By micromanaging our scheduling process you are making our lives difficult, the residents are learning less, and most importantly, the residents hate these regulations. They are always wanting to do something that we can't let them do, even though it would be educational.

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I am director of a hematology/oncology program and have also led our university's deployment of an electronic residency management system throughout its GME enterprise over the last year. In that latter capacity, I have had the opportunity to observe the effects of the duty hour regulations on many other programs at my institution.

My program has had an experience similar to most of the approximately 50 GME programs at the university, in that the new rules were unnecessary for these programs and have served only to consume more of the faculty's and trainees' time with more documentation requirements and more monitoring of activities that don't need monitoring.

My fellows now work more hours—time spent logging their duty hours in the electronic system—than they worked before the new regulations went into effect. I work more hours, too, monitoring the logged hours. And our institutional GME officials work more hours performing a second level of monitoring across all our programs. Actually, we're probably not working more hours performing all this logging and monitoring; we're simply getting less other truly useful work done, ie, we've become less productive.

Of course, the total amount of time spent on this logging and monitoring is not horrendous, but when taken together with all the other incremental documentation burdens trainees, faculty, and administrators have had to assume over the past many years, it's easy to understand why I can find no trainee, faculty member, or administrator who appreciates being subject to the new regulations. Another negative effect is the further reduction in respect I perceive among my colleagues for the organization that accredits their programs as well as for the threatening legislative bodies that seems to be unable to distinguish medicine from aviation and nuclear power generation and is irresponsibly focused on naively simplistic, quick fixes to very complex, long-term problems.

Another major negative effect I have seen in programs that previously had their residents work a full day post-call is the frustration of residents who are instructed to leave their patients as the clock strikes the 31st hour. (They are even more frustrated when they have to leave before post-call rounds in order to get to continuity clinics, which had to be switched from afternoons to mornings out of consideration for the same rule.) We are fortunate to have residents who have a strong sense of professionalism, but that professionalism is grossly assaulted by the commandment to leave their patients before they are fully settled—but I suspect such professionalism will not fare well after 36 months of such daily assaults. The recent calls of medical education regulators for improved teaching of professionalism seem to ring hollow when the same regulators demand trainees abandon their patients because the clock struck a certain hour.

I have heard anecdotes from other institutions—some of which apparently are still wrestling with post-call clinic issues vis-a-vis the new work hour limits—of patients who came for afternoon resident clinics but were turned away because "the doctor is out sick." Upon returning the following week and inquiring of their doctors about their (the doctors') illnesses, these patients were told by their resident physicians that they hadn't been sick but rather had been commanded to go home just before the start of clinic because of the 30-hour rule. It will be interesting to see how long it will be before an adverse outcome resulting from a work hour limit-related delay in care results in a malpractice lawsuit.

Another major negative effect is the significant reduction in educational opportunities forced by the new regulations. I'll cite just one of a myriad of examples that have come to my attention: Our Medical Intensive Care Unit service used to include three upper-level internal medicine residents, each of whom took in-house call once every third night. Through the 36 months of internship and residency, a given internal medicine resident would be assigned to the MICU for 1 to 2 months during internship and 2 to 3 months during upper-level residency. To accommodate the new regulations, the MICU team had to be expanded to include four upper-level internal medicine residents, each of whom takes in-house call once every fourth night. Necessarily, these residents will rotate through fewer non-MICU rotations. Does a fifth or sixth month of MICU service serve the resident, and his future patients, better than a first month of service in another subspecialty? I would guess that most internal medicine educators and residents would quickly choose the first month of service in another subspecialty.

Need more negativity? Even community practitioners are not looking kindly at the new work hour limits. They are not looking forward to hiring potential new partners who never—not once in 36-84 months of "training"—learned how to work a full day post-in-house-call. And there is no escaping the fact that, because of reduced work hours, much of the knowledge and skill that should have been learned during training in some specialties will have to be learned instead on the job, where the structured learning and supervision so important for high-quality medical education are virtually nonexistent.

You also asked, "What about patients?" My observations to date are that, when asked, patients have been only vaguely aware of the work hours issue, and they mildly endorse the popular media's sentiments that less fatigued residents will result in better medical care. No patient who has engaged me on the subject has been able to think of any adverse consequences to the work hours initiatives, but when I point out the potential long-term effects, they suddenly lose their enthusiasm for work hour restrictions and instead suggest the issue needs more thought. I have not encountered a single patient who has acknowledged receiving better care, or truly has received better care, because of the new regulations. I can't say I have witnessed any situations where a patient clearly received worse care because of the new regulations, but I have *heard* of such situations (eg, the "doctor's out sick" anecdote reported above). I have, however, already witnessed in these first three months *many* educational opportunities which have been irretrievably lost to our residents—rounds they could not make, orders they could not write, treatment responses they could not witness, conferences they could not attend, surgeries they could not conduct, etc.

You also asked, "What about the hospital's bottom line?" It's clearly worse, due to the physician extenders who had to be hired.

Nearly 20 years ago a young woman unfortunately died in a New York teaching hospital, largely because of inadequate trainee supervision, not trainee fatigue. Over the ensuing 2 decades, we have come through a series of twists, each one seemingly more surrealistic than the last, only to witness this next step in the devolution of a socially valuable, service-focused profession into a less valuable, timeclock-focused trade. We're now constrained to working our residents no more than 80 hours a week and should consider ourselves lucky we've been allowed 80 hours; some European countries are at 58 hours or less. The trend is clear. Twenty years from now the seeds being sown now at the American public's behest will be reaped, and when incidents mimicking this summer's loss of some of France's 15,000 elderly due to inadequate hospital staffing become common in this country, too, the American public will be scratching its head, asking, "How is it that we have come to have such phenomenal medical technology yet such inadequate doctors and such an inadequate health care system?"

All health care professionals know that (good) medicine is hard to learn and hard to practice. However, this fact is at odds with the evolution of the American ethos over the past few decades to believe that life for all of us—including, now, our doctors—should be easy, not hard. (The latest study of the factors influencing medical students' selection of which specialty to pursue indicates that, more than any other factor—even potential salary!—"lifestyle" is now regarded as most important.) Yes, life should be easy, and in 2003 America, like Europe, believes this so firmly that it is willing to compel its citizens to stand idle. Of course, it is not possible to reconcile this press for idleness with our society's daily demand for services and products which can be provided only by hard work. Our legislators' failure to recognize this irreconcilability and to protect conditions permitting hard work will inevitably result in inferior services and products. This degradation will come slowly, but it will come.

Yes, my community, and every other community in this still great country, will definitely reap the public policy seeds we are sowing. There is no retreat from the current course. The medical profession has already demonstrated how little influence it has on public and Congressional opinion. Congress has already demonstrated how little it is willing to carefully study this complex problem before acting. The ACGME is left no option but to reflexively attempt to regulate what Congress threatens to legislate, and Congressional sponsors of the currently pending legislation won't—politically, can't—do a "180" on this issue even if they come to grips with the harm they are causing for half a billion Americans 20 years from now.

The only question left in my mind is whether the American public will ever regain enough of a meaningful respect for hard work—and enough of a desire for the benefits that hard work brings—to repeal unrealistically simplistic work hour restrictions and instead focus regulatory and even legislative efforts more usefully on issues of supervision and systems integration.

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While on service my own residents complain that they feel the rigidity of the present program interferes with education, as well as continuity of patient care. We need to survey our residents as well as program directors.

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I appreciate your comments and hope that your words are noted at the ACGME.

We are struggling mightily to achieve the 80-hour work week for our trainees in neurosurgery. The trainees are not happy. You cannot learn neurosurgery by reading about it or watching it. You need to do it! Most neurosurgery cases take many hours to perform. Senior residents do not want to leave the operating room at noon to satisfy arbitrary regulations. Traditionally the resident team rounds on the patients at the end of the day. This is a wonderful learning experience for all residents. Now many have to leave before rounding and only a skeleton crew sees the patients. This deprives residents of a vital learning experience.

Residents sleep more under these rules most likely, but in the long run patients are going to suffer because of the many missed training opportunities.

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Sadly, the 80-hour work week enforcement continues to pose surprising ramifications. Some surgical residents now occasionally "defer" participation in certain clinics as some assert they should be allowed to choose their limited hours' experience. Obviously this strains already difficult relationships as leadership evolves on how best to provide adequate training to achieve competency while being forced to reduce resident exposure to teaching opportunities.

The ultimate result will likely be more limited focused areas of clinical adequacy, particularly in surgical specialties. This is not unlike the Russian system where surgeons were trained, for instance, to be thyroid surgeons only. We can only hope that dogma will swing back somewhat.

Also, it is an obvious extension to see laws written to curtail attending physicians' hours, a la airline pilots, truck and bus drivers, etc. Probably the only reason it hasn't happened yet is the realization that there would likely be a sudden huge shortage of "available" surgeons/specialists, etc.

Perhaps Congress would upgrade every physician's reimbursement codes if they truly realized the actual long hours most physicians work; many of these hours are not directly billable. Perhaps we should capitalize on this via education of the public.

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• For the fellows, this has not been an issue and we have made sure that there is continuity and that they voluntarily go home—but they do not like to! Moreover, at the present time, call is not in-house, making this a lesser problem.

• The decreased time that residents have in the care of the patients and the disruption in care is similar to that created by the continuity clinic. We then have to hear negative evaluations such as, "I do not know what's going on with my patient since the attending or fellow wrote orders." Well, if the resident is off to clinic or home after call, NICU care does not stop. We have, however, not had to send residents home at the witching hour! Somebody else monitors that and does it well.

• I have heard anecdotal reports from other directors that residents have stopped right in the middle of a code and stated, "I have to go home."

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One size does not fit all. It makes no sense to have the same regulations that may be appropriate to govern the work hours of a resident at a huge intercity medical center applied to a smaller, rural hospital. There needs to be some way to differentiate between rural hospitals and those in the major urban centers.

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Programs need to have the latitude to ask/allow residents to work, but many hours are required to complete the clinical/educational mission.

If there is a need to monitor outcomes such as resident satisfaction, patient safety, etc, in programs with residents exceeding some work hours threshold, then do that—but what has been done is arbitrary, completely based on anecdote, and detrimental to training programs. Now it should be fixed.

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The current system is terrible:

• There is no continuity of patient care
• Teaching has become non-existent
• House officers are asked to complete same amount of work in shorter period of time
• Consultants are unable to find primary team

We had the best educational and clinical care system in the world, but the academic system has fallen like dominoes, aquiescing to government intervention without any foresight as to impact on patient care (which is clearly suffering) or education (which is suffering to same degree).

We need to unite against this imposition. Alternatively, have a congressman/woman admitted to a teaching hospital and see what happens!

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From my perspective an 80 hour work week is an appropriate number for most training programs.

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It was interesting to read the negative comments about work hour limits. I feel more positive about the duty hour limits every day. I have never seen resident morale/attitude/mood/camraderie this good. Participation in advocacy work is at an all-time high. Residents are interested in learning again, participation in AM report is improved, they are looking up information on the diseases of their patients. We had a record number of recognition awards come from patients and nurses, about our residents, last month.

I am not sure why things are different here. Maybe because we spent a lot of time making system changes so that the requirements could be more easily met. Maybe I worried the residents so much about "shift mentality" that they just want to prove me wrong. Maybe our new emphasis on physician well-being is just helping them realize we really care, and they aren't just a cheap labor force for the hospital.

I think the duty hours may help us achieve physicians that are truly "healthy life-long learners." Hopefully this "duty hours high" will not pass.

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I do not have a negative attitude toward resident hour limits. The not-so-fine line between residency activities that truly are postgraduate "education" and those that represent "service" should be even more evident to programs that previously have chosen not to separate the two. Programs that elect to restrict the service component most assuredly will have been well served by the 80 hours rule. Truly educational activities, including reading and research on campus and at home, should be no more subject to externally imposed regulation than is the learning schedule of the graduate student in nuclear physics or law.

As a traditionally busy specialty, our residency program is attempting to "get it right" about the need to have duty schedules that are humane and geared toward serving the needs of education rather than service. In this regard, the motivation provided by the 80 hours rule has been a positive.

We do worry about those residents who have adopted a "shift mentality." Likely that will pass with appropriate coaching.

Many programs will get it right about the need to have duty schedules geared toward serving the needs of education rather than service. Those programs can hope that the ACGME will allow us to use our own judgment in permitting residents to stay on campus 1 or more hours to complete a patient care episode such as an operative procedure. I think the duty hours can be a positive. Let's continue to try.

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The 80 hour work week has been a disaster both for programs but more importantly for the residents. Most residents expressed dissatisfaction about leaving the middle of rounds and leaving unfinished work. They also feel that they are absent at a most critical time in the care of their patients—the day after admission, when most of the diagnostic tests are occurring—and they have to acquire critical information second hand. Essentially the new guidelines have reduced inpatient learning to an ER mode. Continuity of care is shot.

This is what happens when curriculum is designed by professional educators who have no knowledge of the importance of patient-based learning in the training of physicians. GME programming officers should interview residents and not just PDs.

For now we have no option—we will comply and send the residents home.

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