Faculty Development Fellowship

Resident Work Hours and Efficiency – Literature Review

MAJ John Heflin, MC, USA

(edited for web page by CDR DL Hufford, MC, USN, 03 JUL 99)

Madigan Army Medical Center

Efficiency:

Literature Search Terms

"Internship and Residency" (All MeSH) separately combined with Efficiency, Productivity, Time Factors (MeSH), Hours Worked, Sleep Deprivation (MeSH), Work Schedule Tolerance (MeSH), Time Management NO literature on how to improve resident efficiency or decrease work hours without adding personnel to the hospital Resident Work Hours: In 1987 the average resident spent 73.2 hours/week performing residency-related duties (exclusive of moonlighting). Interns averaged 85 hours/week with surgical specialties averaging over 100 hours/week (4).

1986 study found attending physicians in teaching and non-teaching hospitals to work approximately 70 hours/week and this was not significantly different than the hours worked by the housestaff.

Several surveys conducted on the topic of work hour restrictions for residents and all have very similar results

Majority of residents favor a reduction in the number of hours worked and endorse the 80 hours per week cap

Residents believe that patient care, education, and personal life will improve through a reduction in work hours

Residents oppose lengthening the residency duration to compensate for the reduced training exposure with limited hours

Residents oppose salary reductions to offset their reduced productivity with limited hours

Staff and Senior residents express concerns about development of a "shift mentality" in junior residents

Staff and Senior residents feel that continuity of care is adversely affected with limited hours

Medical leadership express concern about a movement for unionization of housestaff should a limitation on the hours worked per week be legislated / regulated by government New York represents the best available data to analyze how other facilities have approached a limit on the hours worked by the housestaff (amendment to Part 405 of the state hospital code) Specifications of Part 405 Emergency Department – Shift limited to 12 hours for residents and attendings (if hospital ER has > 15,000 visits/yr.), 1 staff per 10 acutely ill patients or 1 per 20 other patients In-hospital Supervision – Continuous in house supervision by a Staff or Senior resident for all junior residents in anesthesiology, surgery, obstetrics, family practice, internal medicine, pediatrics, psychiatry Resident Work Hours Cap – Average of 80 hours worked per week or 320 hours per month (later

decided that the time spent sleeping while on surgical call does not count) , Minimum

of 8 hours off between work days (later dropped), At least one 24 hour period off per week. Ancillary Staff – Hospital must provide 24 hour intravenous, phlebotomy, messenger and patient transport services. Specific numbers of full time equivalent (FTE) providers of each type per hospital bed Statewide Cost of Complying with Part 405 in 81 New York teaching hospitals – 1989 Assessment (7)

Overall – additional 5358 FTE personnel, 3% increase to total annual hospital expenditures

Emergency Department – add 514 FTE Staff physicians (3.6 per hospital)

In-hospital Supervision – add 765 FTE physicians (3.5 per hospital)

Resident Work Hours Cap – Great pressure on Surgical and Obstetric programs, add 1424 FTE

providers (optimal mix of physicians and physician extenders is not known)

Ancillary Staff – add 655 FTE for intravenous support, 933 FTE for phlebotomists, and 1067

messengers and patient transporters

1989 Report of the Executive Council of the Association of American Medical Colleges (8)

Concerns about the New York plan:

Does not recognize differences between the specialties or year of training

Restricted hours may affect the length of time needed to acquire requisite skills

They affect different types of hospitals differently (large university program vs. small community program)

Will produce a major effect on physician manpower, i.e. more residents may be recruited to make fill

the call and rotation schedule Recommendations: Use of an 80 hour work week averaged over 4 weeks (work hours does not include time spent sleeping on call)

Continued use of graded supervision of residents in the emergency room, inpatient wards and outpatient clinics

Gradually phase in changes

Control / prohibition of housestaff moonlighting

Hiring more residents, physician extenders, salaried staff physicians, or increasing the patient care involvement of staff physicians to accommodate the decrease in resident hours

Detroit trial of a Staff vs. Resident inpatient medicine service (10) – 1988

Design – Randomized trial comparing outcomes of general medicine patients randomized to a nonteaching Staff service or a teaching resident service over a 12 month period. Outcomes measures included length of stay, total charges, lab/radiology/pharmacy/supply charges, in hospital morbidity and 6 month mortality, 15 day readmission rate. Results:1) Staff service had a significantly lower average length of stay (1.7 days lower), average total charges ($1,681 lower), and lab and pharmacy charges than the resident service. 2) No significant differences in mortality or readmission rates

Impression – Teaching hospitals may consider an attending service as a way to reduce the work loads on the housestaff and offer more opportunity for training in the outpatient setting

Evaluations of Residents’ Time in Daily Activities:

Duke University (5) – 1992 study comparing housestaff estimates of time worked to random work sampling.

Design – Housestaff on general medicine service provided estimates on how they spent their workdays pertaining to their activities and work contacts. The housestaff then wore random reminder beepers that cued them to record their activity and work contact at the time of the beep in a standardized code book. There was an average of 3.2 signals per hour and data recording occurred for 6 consecutive days (2 call cycles). The number of entries for each category is divided by the total number of activity entries to determine the proportion of time spent. Comparison performed between the housestaff estimates and proportions from random work sampling. (n = 36)

Results – Housestaff estimates of work activities and work contacts totaled over 100% (119 and 106% respectively). Slept an average of 4 hours per call night. Housestaff overestimated the proportion of time spent performing histories and physicals (29 vs. 17% actual), interpreting labs and x-rays (6 vs. 2% actual), teaching (3.6 vs. 1% actual), reading (8.4 vs. 3%), with patients (20 vs. 13% actual), with students (10 vs. 6% actual), with nurses (6 vs. 1.6% actual). The housestaff made good estimates of the time spent in charting and dictating (14% actual). They underestimated the time spent with attending physicians (8 vs. 17% actual) which corresponds to one hour per day of underestimation.

Impressions – Work day estimates based on recall are inaccurate. Random work sampling is pragmatic and inexpensive. Assessments of Resident Education: Columbia Presbyterian Medical Center (NYNY) Obstetrics and Gynecology (1) – Study in response to the 1989 New York State hospital code Part 405 with regulations for residents work hours and supervision Baseline: 110 hours per week, call every third to fourth night, worked the day after call (36hr shift),

One weekend off per month, residents in 12hr shifts 6 days/week

After Change: 75.5 hours per week, gynecologic attending covers the emergency room, physician assistant covers the gynecology floors at night, fourth year residents become a night float coverage, midwives added to labor and delivery 24hrs/day 7 days per week

Design - Review of major surgical case load performed by residents; comparison of scores on annual in-training exam (CREOG); and survey comparing resident and staff perceptions before and after the change in the residents’ work hours (n = 21 residents, 33 staff)

Results: 1) No change in the residents surgical case load

2) 50% lower scores on the annual training exam (not significant but power was only 13%)

3) improved resident quality of life, improved interactions between residents and staff, residents perceived improved sleep and stress level, continuity and quality of care not improved, development of "shift worker" mentality in junior residents, increased time for resident reading, no change in resident education (residents slightly favorable while attendings mildly unfavorable about the changes)

University of Texas Houston Department of Obstetrics and Gynecology (3) – 1995 study of Obstetrics residents' performance on annual in-training exam (CREOG) in relation to study time available Design – Evaluated the in-training exam scores (the standard score, percentile rank within year group, and change in scores for residents taking the exam in consecutive years) for all residents from 1993-1995 related to their short term (one month) and long term (3 months) ability to study on rotations preceding the exam (n = 66). Ob-gyn residents in two programs ranked each rotation for the availability of study time on a four point scale. "tough" rotations were those with ratings in the lower half of the scale and "easy" rotations had scores in the upper half of the scale. Residents were prevented from being on call the night before the exam. Results: No significant correlation found between available study time and subsequent examination scores. Resident scores in the "tough" subgroup were not significantly different than those in the "easy" subgroup. Power for detecting relationship predicting 16% of variance was 85% for standard scores and percentile rank and 68% for the yearly differences in scores. Impression – Would be more beneficial to examine the residents study habits and learning styles than to make schedule adjustments to enhance test performance.

Evaluations of Sleep Deprivation on Resident Learning and Performance: Evaluations of the effect of acute and chronic sleep deprivation on resident performance have not been consistent. The studies have consistently shown that mood, attitude, and perceived efficiency deteriorate with sleep loss. Many of the studies on performance from the 1980s used short psychometric tests and have not shown a deleterious effect of sleep deprivation. In debate is whether the short psychometric tests are capable of assessing sustained cognitive performance in clinical situations. The surgical literature has shown the validity of psychometric tests to predict vigilance, accuracy and organizational abilities. Separate tests by Wilkinson and Donnell have shown that sleep deprivation does not affect performance until 30-50 minutes of testing have elapsed (4). Tasks that are prolonged, dull or repetitive are the most sensitive to sleep deprivation. Tasks involving short laboratory forms, short procedural skills, short written tests of cognitive knowledge, and clinical encounters with actors as patients failed to show changes with fatigue or sleep loss (4). Sleep deprived subjects have shown an ability to compensate for the perceived fatigue at the expense of speed (6).

Penn State Study (4) – 1988 study of family practice residents’ performance on annual in-training exam in relation to sleep deprivation and hours worked. Design – Pennsylvania family practice residents were surveyed at the time of their annual in-training exam about the amount of sleep the previous night, the hours worked per week, and the average on-call frequency. The composite test scores and the amount of sleep, hours worked per week, and on-call frequency were analyzed via regression analysis with each year group examined independently. (21 of 30 programs, n = 353)

Results: Each year group had significantly different composite test scores. A statistically significant decline in composite score with decreasing sleep the night before the exam existed in each year group. The totally sleep deprived scored approximately 30 percentile points below the well-rested residents. No significant relationship existed between the on-call frequency or weekly hours worked and the composite test scores. The scores on the one hour clinical set problems section were not related to any of the study variables. The percentage of residents with less than 4 hours of sleep the night before the exam was 13.9%, 10.2% and 4.5% respectively in the first, second and third years.

Impression – Prolonged testing (> 1 hour) may be required to detect subtle differences in cognitive performance with acute sleep loss.

Medical College of Wisconsin (2) – 1990 study of surgical residents and medical students learning in relation to sleep deprivation. Design – Over a one month period subjects maintained sleep diary, reported perceived fatigue and motivation, read a surgical literature article and were given a 15 question multiple choice test 1 week later (short term recall). A total of 6 articles were given in separate morning sessions and all tests were retaken 3 months later (long term recall). The study subjects were medical students and surgical residents on a trauma service or general surgery service (n = 56). Separate analysis performed for medical students and residents. Trauma service has 36 hours on duty followed by 36 hours off duty while the general surgery service has every third night in hospital call. Sleep deprivation defined as less than 4 hours of uninterrupted sleep during the previous 24 hours (established definition in studies).

Results: 1) One third of subjects were sleep deprived in at least one third of the morning sessions

2) Fatigue scores were higher and motivation scores were significantly lower for the sleep deprived compared to non sleep deprived subjects

3) No difference in short term or long term recall test scores between the sleep deprived and the non sleep deprived - includes analysis of individual test results, analysis of pooled test results (90% power for 1 question difference in pooled analysis), analysis with subjects as own controls, regression analysis, and multivariate analysis of covariance adjusted for test taking ability

Impression – Short term and long term medical learning is not adversely affected by the sleep deprivation in usual on call schedules. Other reviews of sleep deprivation (Asken and Raham, Samkoff and Jacques) have shown that affective state, speed of cognition, and psychomotor functioning are impaired with sleep deprivation but short term recall tasks and brief psychomotor tests are not altered.

Medical College of Wisconsin (6) – 1987 study comparing performance of surgical residents on psychometric tests in relation to sleep deprivation Design – Three cohorts of surgical residents on every other night call were assessed each morning for 18 days. The assessment included completion of a sleep diary, fatigue rating, motivation rating, and five psychometric tests (visual attention, auditory attention, reasoning ability, spatial visualization, and fine motor coordination) requiring 30 minutes to complete. The tests were conducted in a serial repeated fashion and each subject was their own control. Sleep deprivation was defined as less than 4 hours of uninterrupted sleep in prior 24 hours (established definition in other studies). Total daily sleep and longest uninterrupted sleep would be analyzed with the performance measures. (n = 26 with 446 tests)

Results: 1) Sleep deprivation occurred with 89% of the call nights (sleep deprived had mean of 3 hours sleep)

2) Sleep deprivation had a negative effect on fatigue and motivation.

3) Regression analysis demonstrated a learning effect for the psychometric tests and there was no performance difference between the sleep states. Thus the subjects were able to learn when rested and sleep deprived.

4) Analysis of variance showed that sleep deprivation accounted for less than 2% of the variance when sleep deprivation was associated with small but significant changes in psychometric test performance. 5) Investigation of cumulative effects of sleep deprivation did not show a significant difference in performance after the first two sleep deprived night compared to performance after the last two sleep deprived nights in subjects with 10-12 sleep deprived nights. In these subject, performance did improve over time representing a learning effect.

University of Colorado (9) – 1988 study of surgical residents performance on psychometric tests in relation to sleep deprivation Design – Surgical residents of similar training level and on similar rotations were paired and underwent eight neuropsychological tests (assessing repetitive skills, verbal attention, sustained concentration, clear thinking, problem solving, memory, and learning) and completed a survey on mood. The neuropsychological tests required 50-60 minutes to complete. The residents were randomized with one resident being fatigued on the first test and the other being rested. The next test was performed more than 7 days later with the first resident rested and the second fatigued. Fatigue defined as less than 4 hours of sleep on the call night. (n = 42)

Results: 1) sleep deprived residents were less vigorous and more fatigued, depressed, tense, confused and angry

2) No significant difference in performance between the rested and sleep deprived (including those with < 2hrs. sleep)

Impression – Acute sleep deprivation alters mood but does not change performance in tests of concentration, thinking and problem solving.

References:

1. Kelly A, Marks F, Westhoff C, Rosen M, "The effect of the New York State restrictions on resident work hours," Obstet Gynecol, 78(3), Sep 1991; pp. 468-72.

2. Browne BJ, Van Susteren T, Onsager DR, et al., "Influence of sleep deprivation on learning among surgical house staff and medical students," Surgery, 115(5), May 1994; pp. 604-10.

3. Riggs JW, Johnson C, O’Neill P, et al., "Are Residents’ Work Schedules Related to Their In-Training Examination Scores?" Obstet Gynecol, 88(5), Nov 1996; pp. 891-4.

4. Jacques CH, Lynch JC, Samkoff JS, "The Effects of Sleep Loss on Cognitive Performance of Resident Physicians," Fam Pract, 30(2), Feb 1990;pp. 223-9.

5. Oddone E, Guarisco S, Simel D, "Comparison of Housestaff’s Estimates of Their Workday Activities with Results of a Random Work-sampling Study," Acad Med, 68(11), Nov 1995; pp. 859-61.

6. Deaconson TF, O’Hair DP, Levy MF, et al., "Sleep Deprivation and Resident Performance", JAMA, 260(12), Sep 1988; pp. 1721-7.

7. Thorpe KE, "House Staff Supervision and Working Hours. Implications of Regulatory Change in New York State," JAMA, 263(23), Jun 1990; pp. 3177-81.

8. Petersdorf RG, Bentley J, "Residents’ hours and supervision," Acad Med, 64(4), Apr 1989; pp. 175-81.

9. Bartle, EJ, Sun JH, Thompson L, et al., "The effects of acute sleep deprivation during residency training," Surgery, 104(2), Aug 1988; pp. 311-6.

10. Simmer TL, Nerenz DR, Rutt WM, et al., "A randomized controlled trial of an attending staff service in general internal medicine," Med Care, 29(7 Suppl), Jul 1991; pp. JS31-40.

11. Ruby ST, Allen L, Feilding P, et al., "Survey of Residents’ Attitudes Toward Reform of Work Hours," Arch Surg, 125, Jun 1990; pp. 764-8.

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