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Stanford Report, July 9, 2003

Residents’ newly limited work hours require increased efficiency, creativity


As of July 1, the medical center, along with all academic medical centers nationwide, must comply with new rules that ensure patient safety by limiting the total number of weekly and consecutive hours residents may legally work.

While there is broad agreement that trainees must be rested to care for patients safely, most faculty and residents also agree that operating under the new rules from the Accreditation Council for Graduate Medical Education will require creativity, collaboration and increased efficiency.

At the medical center, working groups of faculty and residents have spent months brainstorming solutions and developing new schedules to comply with the rules.

"I think we’re as prepared as we could be," said Ross Downey, MD, a chief resident in internal medicine, who helped develop the department’s new schedule. "We’ve talked about this a lot and thought through all the possibilities."

The rules mean that residents must work fewer hours — a maximum of 80 hours weekly on average, and no more than 30 hours consecutively — but must still fulfill all their patient-care responsibilities and learn everything a physician-trainee needs to know.

"Our challenge is to accomplish the same work in 10 to 15 percent less time. It’s difficult because we’re training our residents in some very technical skills requiring a lot of practice," said Maurice Druzin, MD, director of the obstetrics and gynecology residency program. Compounding the challenge, he noted, no additional funding is being provided to help hospitals comply with the rules.

To address the problem, the internal medicine department formed several working groups comprised of faculty and residents. The groups all agreed on the values they wanted to preserve: delivering high-quality patient care, working with a consistent team of colleagues, and optimizing resident education and well-being. The groups then developed several proposals to meet the requirements, ultimately choosing the one they deemed most workable.

The new schedule introduces two night-float residents who arrive at 10 p.m., allowing the team resident to go home and sleep after completing sign-out rounds. The night floats supervise the remaining two interns until 7 a.m., when the resident returns for morning report. The two interns then go home at 1 p.m., while the team resident remains to complete the day’s work.

This schedule replaces a previous one in which the entire team of a resident and two interns stayed overnight when on call, often working more than 36 consecutive hours.

Peter Pompei, associate program director for the internal medicine residency program, explained that by having the on-call resident and interns overlap through the use of night floats, the resident can get some sleep and continuity of care is preserved by minimizing the frequency with which patients are handed off to physicians less familiar with their status.

The obstetrics and gynecology department’s task was even more complicated because distinct schedules had to be developed for each of its four subspecialties. Druzin and associate program director Scott Oesterling developed proposed new schedules and then melded them into a single basic prototype under which three-person night teams and day teams were created, replacing the previous system of four-person teams that worked shifts of 24 to 36 hours.

Druzin shares the concern of many in academic medicine that when residents must complete their patient-care duties within an allotted time, their educational time might be shortchanged. Under the new rules, then, "You have to eliminate redundancy, eliminate non-educational activities and maximize teaching time," he said.

For example, while junior residents used to spend hours holding retractors for surgical cases, this activity may need to be curtailed because "that time would probably be better spent doing patient work on the floor," Druzin said.

Pompei believes that the culture of housestaff education poses another hurdle, given the tradition of long work hours in medical training. Still, he and most other faculty agree that making sure residents are well rested is important. "The same way we limit the hours pilots can work," he said, "it makes sense to avoid excessive fatigue for our residents so they can provide good patient care."

Greco takes a round of Stanford Hospital residents on a volunteer trip to Haiti (10/16/02)

Pediatric residents at Packard awarded national grants to help teens at risk (1/15/03)