Unintended Consequences: The Accreditation Council for Graduate Medical Education Work-Hour Rules in Practice
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Seventy-nine-year-old Doris K. was admitted to the hospital with weakness at a bad time for my team and me, especially considering the limits of the new 80-hour workweek. It had been a frenetic day. We were swamped with 11 patients who came before Doris K., and her weakness brought us to a dozen. Keeping up was exacting, made worse by the pace: Six new admissions hit the floor in just 3 hours. As one of the interns succinctly put it, we were getting spanked. But in addition to the volume of admissions, our night felt increasingly overwhelming from a unique and novel burden: We had to finish everything by 11:00 p.m. Each of us did the math and tried to conceive of a method of seeing 5 more patients and leaving the hospital in the next two and a half hours. It couldn't be done, and realizing this made us feel exponentially more frazzled, rushed, and suffused with fatigue. This was medical training under the mandatory work-hour restrictions for physicians. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) announced new regulations for residency programs in the United States. Under these rules, all doctors in training must work fewer than 80 hours total in a week, cannot work more than 30 hours in a row, and should have 10 hours off between each shift. The regulations were developed because patients, community leaders, and physicians felt that the training system deprived young doctors of sleep and placed patients at risk. For many residents, the implementation of the ACGME rules this past July was dramatic, resulting in paradigm changes in the structure and function of house-officer teams on the wards. The pressure to comply has been substantial, with at least one program this year sanctioned for violating work-hour rules. My class of third-year internal medicine residents was 1 of only 2 that had trained under both the old and new systems. As interns and junior residents, we endured long overnight calls followed by full postcall daystrials prohibited by the new regulations. These experiences granted us a unique vantage point from which to observe and contemplate the system as it had been, with excessive, potentially unsafe demands placed on residents, and as it had changed, with new conflicts and challenges, many of them unforeseen before the ACGME guidelines. During my residency program last July, for the first time in the hospital's 108-year history, the internal medicine residents on call stopped admitting patients at 9:30 p.m. and left the grounds when their work was completed. The new system abolished sleep deprivation and overnight call for ward residents, a time-honored component of housestaff training since the program's founding. The newfound ability to sleep at home after a hard day of admitting was wonderful. On our night with Doris K., my bedroom had become a beacon of hope at the end of a long, exhaustive effort. However, despite this benefit, under the new system I found that I worked harder than ever. A frantic mentality engulfed the ward, with residents and interns rushing from task to task and then out of the hospital. This was particularly true after 5:00 or 6:00 p.m. when each new admission, each new cross-coverage problem, potentially delayed the steady march toward quitting time. The pragmatic reality of patient care drove this feeling: It was dangerous and impractical simply to walk out each night at 11:00 p.m. like a shift worker when the whistle blows. Work-ups had to be followed through to a reasonable stopping point before we handed off patients to the night team, and this made us rush as time drew on. Life on medical wards has always been harried and demanding, but when I stayed in the hospital overnight as an intern, I felt, I'm here all night. I might as well take my time and learn something along the way. Not being required to sleep in-house and being pressured to leave the hospital was a colossal change. As a result, the pace at which I worked under the new rules was faster than ever. Although other residency programs use various schedule arrangements for ACGME compliance, the issues are universal. As the hour when residents must leave the hospital approaches, each new patient chore is packed into a rapidly dwindling amount of time. A crunch is unavoidable. This new environment makes me wonder if medical errors are increasing, a potentially malicious irony for a system designed to protect patients. I have seen no direct evidence of this, and housestaff seem, as always, obsessively dedicated to giving patients the best care. But with medical mistakes being an alarmingly common occurrence, the rush to leave the hospital should be evaluated objectively for any potential harm to patients. This will undoubtedly be an area of intense scrutiny in years to come. More certain is the effect I have seen on resident camaraderie. During my intern and junior years, if we were stuck in the hospital for the night, if no one was going anywhere, we felt we were all in it together. Most residents stopped to talk, to eat dinner as a group, and to say, Hey, you need a hand with that? Now, we are too often consumed by our individual to-do lists, oblivious to the workload of those around us. On my team's overwhelming night with Doris K., we began working her up late into the evening, despite skipping dinner and dividing our ever-lengthening task list among the entire team. By that time, the other day teams were gone, leaving no one but the night residentsalready busy with their own workto lend a hand or to simply commiserate with about the day. It was clear, at least to me, that something special was lost. A far greater concern is the possible threat of the pace to education. The ACGME regulations catalyzed a slow movement in medicine that developed during my days in medical school: the marginalization of learning. Success in the medical wards, moving patients along, and getting things done often require efficiency above all else. Chores like documenting charts and coordinating follow-up appointments can dominate a resident's to-do list, which makes education about the diagnosis and management of disease feel like a hindrance, a drag on the steady progress through the day. In the new ward environment, we are constantly tempted to sidestep for the sake of expediency decisions that require careful thought. Why look up the differential diagnosis of hematuria when a renal consultant will be called anyway and it's getting late in the night? Why pause to analyze an electrocardiogram when the emergency department has already documented a lack of acute changes and the floor is awaiting orders? Under the new system, the intern who admits 6 patients and discharges 3 others, all the while calling 2 consults, is a champion of the wards. But I still wonder, where does learning fit in? The blame for this does not lie solely with the ACGME rules. Education's de-emphasis on the wards also evolved during my intern and junior years, driven by declining lengths of stay and ever-increasing paperwork for even the simplest discharges. But the ACGME regulations rapidly accelerated this process so that learning, at all levels, from medical students to senior residents, has been diluted, drowned by a sea of discharge planning, case management, and pressure to get done and get out. What did all of this mean for Doris K. and her weakness? We met her late into our call night, delaying the trip home to our beckoning apartments. We tried to ignore our fatigue and the pressure to rush out the door so she could receive the care and attention she deserved. I think we were successful, and her hospital course was uneventful. But I am certain that with all the Doris K.s admitted late in the night by teams desperate to go home, mistakes will occur. Although we have eliminated the unsafe excesses of the old system, we have generated a new set of conflicting pressures that will shape the next generation of internists. What kind of attending physicians will Doris K. meet in the future, once the entire profession has been trained under the current system? Will they clock out like shift workers each day despite lingering patient needs? Will they feel a sense of community with their colleagues? Will they be broad-thinking diagnosticians or simply assembly-line workers, shuffling patients through the medical system? Only time will tell, but the ACGME should look hard at these unintended effects from the work-hour restrictions and develop strategies to avoid them. These trends cannot be ignored: The way we work and train as residents now is the way we will heal as practicing physicians later. The system molds us into doctors, and as doctors, we will define the U.S. health care system in years to come.