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Dr. Kathlyn E. Fletcher was fresh out of residency and completing her fellowship training at the University of Michigan when the Accreditation Council for Graduate Medical Education (ACGME) began limiting resident duty hours in 2003. She grew concerned that the limits would lead to unintended consequences, such as poor patient handoffs and less prepared trainees.
So she teamed up with one of her mentors, Dr. Sanjay Saint, and other colleagues at the University of Michigan and the Ann Arbor Veterans Affairs Medical Center, on a research project that would examine the link between resident work hours and patient safety (Ann. Intern. Med. 2004;141:851-7). Over the next decade, Dr. Fletcher published research examining several aspects of the duty-hour issue, from how it impacts patient perceptions to transitions of care.
Now an associate professor of medicine at the Medical College of Wisconsin, Milwaukee, and a hospitalist at the Milwaukee Veterans Affairs Medical Center, Dr. Fletcher explained how resident duty-hour restrictions have changed the way hospitalists work.
Hospitalist News: You analyzed the impact of resident work-hour restrictions in 2004 and 2011. What have we learned over the last decade?
Dr. Fletcher: In 2004, there really wasn’t very much data about the impact of reducing hours. We had some data from New York because they had actually gone through a similar restriction process a number of years prior to that. There was quite a bit of data available about the impact on residents’ lives, but very little on what was likely to happen to patients. Even back then, it seemed clear that the quality of life for residents would improve during residency.
Fast-forward to the reviews that I published in 2011 with Dr. Vineet Arora and Dr. Darcy Reed to help the ACGME decide what they should do next (J. Gen. Intern. Med. 2011; 26: 907-19). We looked at the impact of the first round of duty-hour rules. It’s pretty clear from the resident standpoint that they are less tired and probably less burned out, and that other quality of life factors have likely improved. From the patient perspective, things have at least stayed the same, if not gotten a little bit better. There are a few very-high-quality studies looking at this issue, but no randomized controlled trials, so it’s impossible to say for sure. For the most part, it looks like these changes haven’t had an impact on the quality of care that’s occurring right now. Patient care has probably stayed the same and resident quality of life has improved.
HN: Transitions of care are increasingly important for hospitalists. How do resident work hours impact this area?
Dr. Fletcher: The whole duty-hour rules debate has cast a lot more light on how important an issue high-quality transitions are. We’re all paying more attention to it. With the residents working fewer hours and working fewer consecutive hours, that’s opened up the field for hospitalists to move in and take over some of the responsibilities that had previously fallen to residents. Hospitalists have more transitions to deal with because they have more patients. But I think that this whole change has really given hospitalists the opportunity to take the lead on defining what high-quality transitions are and doing some of the really good research on what high-quality transitions look like. Look at Dr. Vineet Arora’s body of work. She has really worked on defining what a high-quality transition is, and how you assess that. I think that’s probably one of the main ways that the duty-hour rules have impacted hospitalists. They brought to light this issue, and the hospitalists just ran with it.
HN: How have these restrictions impacted the training of future hospitalists? Are they prepared when they step out of training?
Dr. Fletcher: The good news for hospitalists is that the way residents are trained is really to become hospitalists. Of all of the specialties, residents are probably most ready to take on that job. But I still think they are coming out of training less qualified than they were before. I am starting to see this in my practice. The education is starting to lag behind a little bit, and I think that this is mostly because residents just aren’t getting exposed to as much before. Figuring out how to balance overwork with exposure to more clinical situations is the most important question for training right now. Moving forward in the next decade, we have to ask, are the physicians being trained ready to be independent practitioners? I’m worried that they are not.
HN: What is next for you in terms of research?
Dr. Fletcher: I have been spending more time writing about and researching workload for inpatient physicians. I still focus quite a bit on resident physicians. It’s not totally independent of work hours because one of the concerns with decreasing work hours is that the intensity of the work increases. The amount of work doesn’t decrease in proportion to the time, so there’s still more work to be done in less time. How does that impact the residents and the patients? That’s where I’m going now.
–Mary Ellen Schneider
Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected]. Read previous columns at ehospitalistnews.com.
Dr. Kathlyn E. Fletcher was fresh out of residency and completing her fellowship training at the University of Michigan when the Accreditation Council for Graduate Medical Education (ACGME) began limiting resident duty hours in 2003. She grew concerned that the limits would lead to unintended consequences, such as poor patient handoffs and less prepared trainees.
So she teamed up with one of her mentors, Dr. Sanjay Saint, and other colleagues at the University of Michigan and the Ann Arbor Veterans Affairs Medical Center, on a research project that would examine the link between resident work hours and patient safety (Ann. Intern. Med. 2004;141:851-7). Over the next decade, Dr. Fletcher published research examining several aspects of the duty-hour issue, from how it impacts patient perceptions to transitions of care.
Now an associate professor of medicine at the Medical College of Wisconsin, Milwaukee, and a hospitalist at the Milwaukee Veterans Affairs Medical Center, Dr. Fletcher explained how resident duty-hour restrictions have changed the way hospitalists work.
Hospitalist News: You analyzed the impact of resident work-hour restrictions in 2004 and 2011. What have we learned over the last decade?
Dr. Fletcher: In 2004, there really wasn’t very much data about the impact of reducing hours. We had some data from New York because they had actually gone through a similar restriction process a number of years prior to that. There was quite a bit of data available about the impact on residents’ lives, but very little on what was likely to happen to patients. Even back then, it seemed clear that the quality of life for residents would improve during residency.
Fast-forward to the reviews that I published in 2011 with Dr. Vineet Arora and Dr. Darcy Reed to help the ACGME decide what they should do next (J. Gen. Intern. Med. 2011; 26: 907-19). We looked at the impact of the first round of duty-hour rules. It’s pretty clear from the resident standpoint that they are less tired and probably less burned out, and that other quality of life factors have likely improved. From the patient perspective, things have at least stayed the same, if not gotten a little bit better. There are a few very-high-quality studies looking at this issue, but no randomized controlled trials, so it’s impossible to say for sure. For the most part, it looks like these changes haven’t had an impact on the quality of care that’s occurring right now. Patient care has probably stayed the same and resident quality of life has improved.
HN: Transitions of care are increasingly important for hospitalists. How do resident work hours impact this area?
Dr. Fletcher: The whole duty-hour rules debate has cast a lot more light on how important an issue high-quality transitions are. We’re all paying more attention to it. With the residents working fewer hours and working fewer consecutive hours, that’s opened up the field for hospitalists to move in and take over some of the responsibilities that had previously fallen to residents. Hospitalists have more transitions to deal with because they have more patients. But I think that this whole change has really given hospitalists the opportunity to take the lead on defining what high-quality transitions are and doing some of the really good research on what high-quality transitions look like. Look at Dr. Vineet Arora’s body of work. She has really worked on defining what a high-quality transition is, and how you assess that. I think that’s probably one of the main ways that the duty-hour rules have impacted hospitalists. They brought to light this issue, and the hospitalists just ran with it.
HN: How have these restrictions impacted the training of future hospitalists? Are they prepared when they step out of training?
Dr. Fletcher: The good news for hospitalists is that the way residents are trained is really to become hospitalists. Of all of the specialties, residents are probably most ready to take on that job. But I still think they are coming out of training less qualified than they were before. I am starting to see this in my practice. The education is starting to lag behind a little bit, and I think that this is mostly because residents just aren’t getting exposed to as much before. Figuring out how to balance overwork with exposure to more clinical situations is the most important question for training right now. Moving forward in the next decade, we have to ask, are the physicians being trained ready to be independent practitioners? I’m worried that they are not.
HN: What is next for you in terms of research?
Dr. Fletcher: I have been spending more time writing about and researching workload for inpatient physicians. I still focus quite a bit on resident physicians. It’s not totally independent of work hours because one of the concerns with decreasing work hours is that the intensity of the work increases. The amount of work doesn’t decrease in proportion to the time, so there’s still more work to be done in less time. How does that impact the residents and the patients? That’s where I’m going now.
–Mary Ellen Schneider
Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected]. Read previous columns at ehospitalistnews.com.
Dr. Kathlyn E. Fletcher was fresh out of residency and completing her fellowship training at the University of Michigan when the Accreditation Council for Graduate Medical Education (ACGME) began limiting resident duty hours in 2003. She grew concerned that the limits would lead to unintended consequences, such as poor patient handoffs and less prepared trainees.
So she teamed up with one of her mentors, Dr. Sanjay Saint, and other colleagues at the University of Michigan and the Ann Arbor Veterans Affairs Medical Center, on a research project that would examine the link between resident work hours and patient safety (Ann. Intern. Med. 2004;141:851-7). Over the next decade, Dr. Fletcher published research examining several aspects of the duty-hour issue, from how it impacts patient perceptions to transitions of care.
Now an associate professor of medicine at the Medical College of Wisconsin, Milwaukee, and a hospitalist at the Milwaukee Veterans Affairs Medical Center, Dr. Fletcher explained how resident duty-hour restrictions have changed the way hospitalists work.
Hospitalist News: You analyzed the impact of resident work-hour restrictions in 2004 and 2011. What have we learned over the last decade?
Dr. Fletcher: In 2004, there really wasn’t very much data about the impact of reducing hours. We had some data from New York because they had actually gone through a similar restriction process a number of years prior to that. There was quite a bit of data available about the impact on residents’ lives, but very little on what was likely to happen to patients. Even back then, it seemed clear that the quality of life for residents would improve during residency.
Fast-forward to the reviews that I published in 2011 with Dr. Vineet Arora and Dr. Darcy Reed to help the ACGME decide what they should do next (J. Gen. Intern. Med. 2011; 26: 907-19). We looked at the impact of the first round of duty-hour rules. It’s pretty clear from the resident standpoint that they are less tired and probably less burned out, and that other quality of life factors have likely improved. From the patient perspective, things have at least stayed the same, if not gotten a little bit better. There are a few very-high-quality studies looking at this issue, but no randomized controlled trials, so it’s impossible to say for sure. For the most part, it looks like these changes haven’t had an impact on the quality of care that’s occurring right now. Patient care has probably stayed the same and resident quality of life has improved.
HN: Transitions of care are increasingly important for hospitalists. How do resident work hours impact this area?
Dr. Fletcher: The whole duty-hour rules debate has cast a lot more light on how important an issue high-quality transitions are. We’re all paying more attention to it. With the residents working fewer hours and working fewer consecutive hours, that’s opened up the field for hospitalists to move in and take over some of the responsibilities that had previously fallen to residents. Hospitalists have more transitions to deal with because they have more patients. But I think that this whole change has really given hospitalists the opportunity to take the lead on defining what high-quality transitions are and doing some of the really good research on what high-quality transitions look like. Look at Dr. Vineet Arora’s body of work. She has really worked on defining what a high-quality transition is, and how you assess that. I think that’s probably one of the main ways that the duty-hour rules have impacted hospitalists. They brought to light this issue, and the hospitalists just ran with it.
HN: How have these restrictions impacted the training of future hospitalists? Are they prepared when they step out of training?
Dr. Fletcher: The good news for hospitalists is that the way residents are trained is really to become hospitalists. Of all of the specialties, residents are probably most ready to take on that job. But I still think they are coming out of training less qualified than they were before. I am starting to see this in my practice. The education is starting to lag behind a little bit, and I think that this is mostly because residents just aren’t getting exposed to as much before. Figuring out how to balance overwork with exposure to more clinical situations is the most important question for training right now. Moving forward in the next decade, we have to ask, are the physicians being trained ready to be independent practitioners? I’m worried that they are not.
HN: What is next for you in terms of research?
Dr. Fletcher: I have been spending more time writing about and researching workload for inpatient physicians. I still focus quite a bit on resident physicians. It’s not totally independent of work hours because one of the concerns with decreasing work hours is that the intensity of the work increases. The amount of work doesn’t decrease in proportion to the time, so there’s still more work to be done in less time. How does that impact the residents and the patients? That’s where I’m going now.
–Mary Ellen Schneider
Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected]. Read previous columns at ehospitalistnews.com.
