Have Resident Work Hours Limitations Helped?

The intent of resident work hours limitations was to improve the quality of care received in the nation’s teaching hospitals. There have been numerous consequences of the limitations - upon primary care, medical education value, and surgical training. The quality of care has not improved.

Primary Care Impacts

Based on lost resident workforce, over 30,000 nurse practitioner and physician assistant graduates have been hired to become teaching hospital workforce. Losses in resident workforce may have been a reason for the rapid movement toward hospitalist design. Studies of the benefits of hospitalist workforce (half day stay saved) have 11 of 17 been done in academic centers. These studies have encouraged widespread adoption of hospitalist workforce. It is interesting that hospitalists may have limited overall benefit in lower volume and other facilities. 

Hospitalist focus has resulted in a second 30,000 loss of primary care trained physicians to become hospitalists with an even more rapid decline in primary care internal medicine (24,000 hospitalists).

It is hard to recover primary care when 60,000 primary care trained clinicians have been diverted to hospital and teaching hospital workforce in the past 12 years. 

The health access result is also major as these 60,000 have been moved to geographic locations with top concentrations of clinicians. Designs that result in greater concentrations of clinicians are certainly in the opposite direction from the recovery of basic health access.  

Primary care training, still forced through the nation’s teaching hospitals, is now largely taught by faculty who are hospitalists. Should primary care training still be stuck inside hospitals by payment and training location designs? Can the nation ever put the proper emphasis on primary care and health access with hospital based designs? 

Value of Medical Education

Value in medical education would be defined as better training for lower cost. Longer training with higher cost for less experience is not better value in medical education.

Residents already seek longer training and fellowships at levels higher than ever – in no small part due to insufficient medical education. 

Longer training means higher debt and lesser life income for future physicians. This is also not value.

It is not “value” to the nation to have to train more physicians at higher cost for the same or less workforce result due to the adverse impacts of medical education changes. 

When graduating residents are not comfortable, they take on more responsibility, with less responsibility trickling down to other residents or medical students. It is hard to learn to be a physician when physician responsibilities are being depleted all along the length of medical education training.

Too many to train on too few patients with training involving substantially less time from a resident is a poor design.

The Case of Surgical Training

Regulations have long been impacting the value of surgical training. Efficient surgical facilities are more like assembly lines with patients in various stages before, during, and after surgery. Surgical residents once represented an advantage to the care of patients in all these stages, until they were restricted from doing so. Onerous requirements for direct supervision have made teaching hospital surgery inefficient by design.

Work hours limitations act to further weaken surgical case numbers and patient experiences during training.

The old model is immersion in physician training. The new model has become part time medicine.

Dubious Claims of Work Hours Benefits

There is the potential that limitations can result in less exhaustion and less stress during training. The question is whether residents use their time off for sleep or relaxation.

Physician work is stressful for those in training and for those in practice. Physicians work hard and they play hard. The decision for work or play is specific to the individual. Life balance is not restored by regulations or limitations.

When residents are not at the hospital, what are they doing? Before residency in teen years, in college years, and in medical school years, long waking hours with high levels of activity are common. Sleep can be limited.

Are residents better off interacting with so many other areas other than medicine – by design? Do residents reign in their "outside" activities to enhance their sleep or improve their learning? There are numerous distractions of all types. Does more time for distraction help?

The main impetus of resident work hours was quality of care improvement. This has not been the case. Teaching hospitals have had the chance to find out that care quality is about the patient. It is the social determinants and situations of the patient that determine teaching hospital outcomes. Factors largely outside of the hospital determine care outcomes. Teaching hospitals understand this well enough to lay claim to more revenue to cover their losses – losses due to caring for patients with greater complexity and poorer outcomes.

There is much to learn from changes in medical education, but mostly there is much more to learn.

Best of Basic Health Access

Robert C. Bowman, M.D.
 SMART Basic Health Access


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