Adverse Effects of Restricted Resident Duty Hours on Patient Care, Education, and Faculty Satisfaction
Abstract & Commentary
By Leslie A. Hoffman, PhD, RN, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert.
Dr. Hoffman reports no financial relationship to this field of study.
Synopsis: The majority of key clinical faculty reported worsening in continuity of care, physician-patient relationships, education and accountability due to restricted duty hours.
Source: Reed DA, et al. Arch Intern Med. 2007;167:1487-1492.
The goal of this study was to elicit views of key clinical faculty members regarding the effects of residency duty-hour limits on patient care, education, professionalism and faculty satisfaction. Key clinical faculty members were defined as active clinicians who dedicated at least 15 hours a week, on average, to teaching in an internal medicine residency program. Program directors were excluded. Participants were selected from a national sample of 39 residency programs chosen to reflect variations in program size and NIH funding.
Of 154 faculty members who were sent surveys, 111 (72%) responded. Most respondents (75%) had 5 or more years of teaching experience, and one-third had at least 15 years' experience. The majority reported worsening in the continuity of patient care provided by residents (87%), residents' communication with patients and families (66%), and the overall quality of patient care (60%) as a result of duty-hour limitations. In addition, they perceived decreased opportunities for didactic (69%) and bedside (73%) teaching, performing procedures (57%), and resident autonomy (57%). Approximately half (51%) perceived a decrease in professionalism. Conversely, they perceived an improvement in residents' well-being, including level of fatigue (85%) and life balance (81%).
Slightly more than half of key clinical faculty members (56%) reported decreased overall satisfaction with teaching and 33% reported a decrease in satisfaction with their careers as a result of duty-hour limits. A minority (40%) reported that they felt less able to develop mentoring relationships with students. Key clinical faculty who spent at least 15 hours a week teaching were more likely to report worsening of teaching opportunities (odds ratio [OR], 5.03, 95% CI, 1.77-14.33) and quality of care (OR, 2.38; 95% CI, 1.14-4.99) in the context of restricted resident duty hours.
Commentary
Residency duty hour limits were implemented to reduce the risk of adverse events from sleep deprivation. While studies support an improvement in residents' well-being and quality of life, the impact on patient care and clinical teaching remains unclear. The impact on faculty workload and satisfaction is important because there are few rewards for good teaching beyond personal satisfaction. Teachers who are disillusioned are more likely to leave teaching and may not advocate their specialty to students.
In this study, clinical faculty believed that duty hour limits had negative effects on continuity of care, communication with patients and families, and the overall quality of care. This is not unexpected. At one hospital, efforts to comply with the change in rules led to an average of 15 handoffs per patient during a 5-day hospitalization. Each intern was involved in more than 300 handoffs during a month-long rotation, a 40% increase over that reported before duty-hour limits.1 With 6 million patients receiving care in US teaching hospitals each day, the impact on patient safety is potentially huge.1
Teaching hospitals are admitting patients who are older and sicker and discharging them more quickly—factors that have increased the workload of residents and faculty, independent of duty hour limits. Educational programs require more trainee supervision, and faculty members are held accountable for patient length of stay as well as generating salary through billing. The patient care team is likely to include nurse practitioners, physician assistants, and/or hospitalists, factors that increase the number of individuals who need to be apprised of the current and revised management plan. These challenges also likely contribute to the perceived decrease in faculty satisfaction. It is important to address ways to improve faculty satisfaction, given the pivotal role clinical teaching plays in educating the care providers of tomorrow.
Reference
- Okie, S. N Engl J Med. 2007;356:2665-2667.
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