32 Ideas for Achieving Work-Hours Compliance
David W. Easter, MD, FACS, Program Director and
Carol Runge, Program Coordinator
University of California, San Diego (UCSD)
Originally Published by the American College of Surgeons
The controversy over work-hours regulations has abruptly shifted from ‘should we do it’ to ‘how can we do it.’ Program directors, residents, hospitals, and our many publics are all intensely invested in achieving these strict mandates. Indeed, even the future strength of our profession, i.e., our ability to attract the best and brightest medical students into surgical fields, may hinge upon how we deal with these complex issues.
The goals and requirements of our residency programs have been significantly expanded. We now seek to train capable surgeons in an increasingly complex field while simultaneously limiting their hours of clinical exposure. These goals are achievable, but not without significant risks and stressors. By sharing our common experiences during this critical time of social evolution, it may be possible to avoid false starts and/or errors in the methodology needed to achieve our common goals.
At UCSD, we have found it useful to make specific changes and additions to our residents’ work environment. We are very much considering further modifications to meet the new regulations. We have also determined that some ideas—which may very well work elsewhere—will likely not have a place in our program. These changes and ideas are listed in the Table. A brief description of the merits of each idea follows. In the effort to meet the potentially conflicting goals of regulating work-hours versus retaining quality education, it is our hope that this exposé will further stimulate productive changes in the culture of surgical residency education.
Certain truisms exist:
- None of these ideas are unique to any one institution.
- Very few tools will be applicable in all settings. Most require more resources than are traditionally available to program directors alone.
- Moral or educational pressures work almost as well as economic persuasion. Cost matters.
- Many attendings and administrators will be resistant to any, or many, of these suggestions.
- Times are changing. Today’s fixes will not necessarily last.
A glossary of terms and ideas:
Changes in place already at UCSD:
1. Hire MD extenders. Creating funding for this option is the big hurdle. Our battle was won when we demonstrated that without nurse practitioners or physician assistants, patient care and timely hospital discharges were jeopardized.
2. Specify OFF CALL days. This was one of our first steps to change the culture of our residents and attendings. Specifying which days are off call empowers the residents to anticipate and claim expected working conditions.
3. More cross covering. Training residents for their future jobs fits nicely with this change. Most attending surgeons cover multiple hospitals, and all surgeons cross cover each other for travel, vacations, etc. Reasonable in-house service coverages are very problematic without increased cross covering. Critical sign-outs and specific mechanisms for back up help are mandatory.
4. No OR downsizing with cases pending. When OR administration sends their staff home with cases pending, the direct result is prolonged working hours for our residents. This battle was also won with the argument of early hospital discharges as a concurrent goal. How can we send patients home before noon when our cases are delayed until 10 p.m. the night before?
5. Add OR scrub techs to selected cases. The second resident at the OR table is certainly an educational experience at times, but, it makes compliance with the 80-hr work-week very difficult. Especially with multiple cases competing for resident time with ward or clinic activities, it is often the best compromise to keep only the operating resident in the OR. Otherwise, discharges and other resident activities are delayed, and work hours are extended. The very real chance of having to cancel big, elective cases for lack of a second resident assistant convinced the OR administration to provide more OR scrub techs for selected, scheduled cases.
6. Enhanced information technology. Computer physician order entry (“CPOE”, in our shop) was very difficult to accept in its infancy. However, it does allow the resident to write orders on any patient from any location, e.g., the OR, ER, or even from home. While not completely online, much of our in-patient chart is available to residents with-out having the chart in hand. This allows for better continuity of care in preparing for cases, seeing clinic patients, etc.
7. Videotape key lectures. The 1-in-7 day off rule mandates that residents will necessarily miss key conferences—hopefully somewhat less than 1-in-7 days! Our residency has made available to residents the videotapes of the institutional core lecture series. We do not specifically require full attention to these available lectures, much as we do not monitor residents who may be drifting off to sleep during certain grand rounds talks. Plus, we duplicate the core of this curriculum into our standard Grand Rounds conferences.
8. Add lectures to Web site. We have requested that all key lectures—specifically Grand Rounds—be submitted in an electronic format, so we can add them to our Web site. Residents can then view or review these useful presentations much as they otherwise study—from home or during quiet in-house call periods.
9. Use more e-mail and text paging. Residents suffer from pager overload. Our residency administration has moved all non-urgent business to e-mail correspondence. Urgent, but not emergency, matters are handled as much as possible by text pages. We try very hard to not initiate “pager phone tag” with our residents.
10. Weekly work hour quizzes. How better to change the culture of our residents and attendings than by avidly improving communication about these critical regulations? The residents and attendings get quizzed after each Morbidity and Mortality conference regarding the new rules.
11. More call from home. See item number four on OR downsizing. Residents must be prepared and eager to come in from home for any concerns. Remember, most attending surgeons do not sleep in the hospital, so we must train our residents to understand this home-triage responsibility.
Changes under consideration:
12. Night float coverage. We have actually tried this method, but to date are not happy with the unintended consequences. Our night float residents are not happy with their OR caseload, nor with the discontinuity of care inherent in this method.
13. Add NDPs to program. Non-designated preliminary residents (NDPs) are a useful workforce for many programs. While NDPs are less expensive to hire than nurse practitioners (NPs) or physician assistants (PAs), they do compete for available OR cases and educational opportunities. A better solution might be to entice non-surgical trainees into our rotations, e.g., family medicine residents, who need this curriculum. Regulated work hours helps to attract these “resident-extenders.”
14. Combine services. There are not enough residents to have separate services for every surgical sub-sub-specialty. We already have combined services, e.g., the Red Service includes vascular, oncology, and other interests. Transplant currently stands alone. It may be useful to re-combine our Transplant Service with the Red Team.
15. Withdraw from affiliates. Whoa! Don’t let this consideration out unless you’ve worked through all available alternatives. But, does that long-established affiliate truly offer unique educational opportunities for your residents? How is the caseload mix? Hmmmmm.
16. Restrict pages from RNs/staff. All nurses and staff members are motivated to quickly solve patient care problems. They are not motivated to avoid resident fatigue or shorten resident work-hours. Things work differently with attendings at private hospitals. Physician well-being is a real concern of any caring hospital’s workforce. We have threatened to restrict or divert all pages between the hours of midnight and 6 a.m. to attendings. While not enacted yet, our staid and frequently time-abusive cultures will change—guaranteed.
17. Triage pages through charge RNs. Gone are the days when charge nurses actually took charge of the flow of requests to physicians and trainees. In a curious parallel, the days of nurses accepting verbal orders from residents/attendings are quickly vanishing. How about a little creative bartering: less verbal orders for more active triage of resident paging activities?
18. Withdraw from non-essential faculty. Whoa, again! We have begun to scrutinize which faculty are “keepers,” and which few faculty are less helpful to our primary mission of training surgeons. Remediation steps for less-than-effective attendings should be readily available if one is ready to “pull this trigger.”
19. Discontinuous resident coverage on services. Does our pediatric surgery rotation always get a PGY-3 resident? Will only a PGY-2 do? How about no resident for one or two months? We have used this tool, occasionally and reluctantly, but not as a permanent programmatic change.
20. Pay for Internet/hospital access from home. All of our residents have home Internet providers. If we expect residents to log in from home for educational activities and physician order entry, etc., why shouldn’t we pay for such access? At UCSD, that cost would be $10 per month, per resident. We have not yet convinced our hospital’s GME budget that this is a valid, if minimal, expenditure.
21. Move key teaching conferences. UCSD is one of the remaining few residency programs to have its Grand Rounds and Morbidity and Mortality conferences on Saturdays. We like our educational time to remain sacrosanct. This decision was more easily justified with the 1-in-7 rule, i.e., somebody was going to miss our key conferences if they occurred on any day of the week. We are still considering moving them, admittedly, because more of our residents get scheduled for Saturdays off than weekdays off. We tried to barter with the hospital on this issue i.e., trade Saturday conference time for OR available time on Saturdays, thereby not losing valuable OR time in the week and not keeping all residents in on Saturdays. So far, this argument has not prevailed.
22. Efficiency training. Our chief residents are casually in charge of this critical educational task. But, we need to formalize this training as soon as possible.
23. Research residents to spell clinical residents. We already occasionally ask our resident(s) in their lab year to take call, or help out transiently, when other residents travel, are sick, or etc. It may become very useful to structure this cross covering schema. Our lab residents uniformly find these experiences to be useful (to keep current with clinical issues), so long as it is planned well in advance, and not too frequently.
24. Create non-teaching services. Every program has an abundance of one educational experience, e.g. trauma. Especially where patient volumes are more than adequate, it may become useful to split the busy service. One becomes the teaching service, retaining the experiences that are rich in desirable education, and the other is managed by physician extenders who report directly to attending surgeons. Billing encounters may be enhanced in this model, and we could easily teach our residents how to interact with these key personnel.
25. Free transportation for fatigued residents. We have not been able to convince our hospital that this is a minimal expense that is very much worth the investment. Consider the risks of one lawsuit! Certainly, residents will not over-utilize this service—they won’t want to leave their car behind. Lots of cluck for that buck.
Options not likely to be used:
26. Increase to 88-hr maximum. This is the wrong message to send to our residents and resident applicants. Focusing on education and cutting out the scut will achieve our combined goals.
27. Eliminate teaching services. We have already trimmed a lot of non-essential services from our residency program. Rather than eliminate a service, we may have to collapse two services into one, e.g., Transplant into the general surgery Red Service.
28. Direct 1:1 attending mentorships. This may work for other programs, where the number of teaching attendings approximates the number of residents in the program. Our attendings tend to have multiple, non-teaching responsibilities that would prevent a valid full-time apprenticeship model from working.
29. PDAs for all residents. PDAs can be used to facilitate sign-outs, data entry, evaluations, and other professional activities of our residents. We believe that this should be a part of the resident’s initiative and choice—similar to the decision of which Internet provider meets their individual needs.
30. Move education to off-site locations. This crafty idea will not allow a diminution of the work hours if part of the established curriculum. What is true, however, is that we all must devise and stimulate more structured, independent learning by our trainees while not at work. As currently defined, work is location and curriculum dependent. If they are at the location of work, or it is part of the defined curriculum, e.g., conferences, then it adds to the hours of work.
31. Extend years of training. While this may be a quick reaction among those without a lot of imagination, this option will make for a very difficult match list for any program proposing more than 5 years of clinical training. Indeed, the American Board of Surgery and other groups are testing early specialization tracks that will shorten many residents’ commitment.
32. Research residents routinely on call. Residents “in the lab” should be routinely doing research, not taking call. Eating into their research time will only dilute their productivity in this special year or years of training. Resist routine intrusions on research residents’ time. The benefit will not be worth the cost.
Like modern Darwinism as applied to social structures, things remain stable for long periods of time, only to be punctuated by periods of intense stress and rapid evolution. Such are the times for surgical education. Those who do not adapt quickly and efficiently will be left behind. Importantly, trainees in surgical education—our most important public—are quick to adapt and register these changes. The best programs in surgical education will lead the way with necessary improvements.