Recreating the residency

On the night of March 4, 1984, an 18-year-old patient named Libby Zion was admitted to the emergency room of Cornell Medical Center’s New York Hospital complaining of fever and an earache. Just hours later, while in the care of the hospital’s residents, she lay dead. Zion’s father, Sidney Zion, was a prominent, well-connected journalist and a former federal prosecutor, and in what would soon become notorious as “the Zion case,” he and his wife filed suit, claiming that the negligence of the hospital’s overly fatigued and poorly supervised house staff was the direct cause of their daughter’s death.

In the end, a New York grand jury did not find sufficient evidence that overtired residents were responsible for Zion’s death, and postmortem lab results suggested that she had died from an overdose of cocaine. But the enormous publicity surrounding the Zion case cast a bright light on aspects of graduate medical education that the American public had long ignored. Medical residents’ duty hours, once an esoteric and jealously guarded prerogative of medical school faculty and hospital administrators, had become the focus of intense interest on the part of legislators and regulatory boards nationwide.

In the wake of the Zion case, New York state and Puerto Rico enacted statutes that set limits on duty hours for hospital house staff. But the most significant shock wave from the case wasn’t felt until July 2003, when the Accreditation Council for Graduate Medical Education (ACGME), citing concerns for patient safety, imposed strict limits on residents’ duty hours at all teaching hospitals. Though the rules themselves are straightforward—they limit residents to an 80-hour workweek and 24 continuous hours on call, and guarantee one day off each week—they have set off a sea change in American medical education and patient care. The traditional residency system was deeply ingrained in the educational structures of medical schools, and the presence of hardworking, inexpensive house staff has long been taken for granted by hospitals in their day-to-day operations.

Yale is no exception. Some 175 new residents in specialties as diverse as anesthesiology and urology arrive in New Haven each year. Though most of these residents are technically employees of Yale-New Haven Hospital (YNHH), the dual educational and clinical missions of residency are reflected in the Graduate Medical Education Committee, which directly oversees the program and reports both to the chief of staff at YNHH and to the dean’s office at the School of Medicine.

Some residency programs, such as pediatrics and psychiatry, have adapted fairly easily to the new rules, but for others the regulations have forced a sweeping re-evaluation of both education and patient care. For example, the sheer size and complexity of the residency program in internal medicine, which shepherds 180 residents through 13 clinical rotations at four different hospitals each year, have required painstaking organizational and educational adjustments.

“The structure of the program at Yale has been built over the last 50 years, and it has been built in pieces, so nobody knew when you changed one piece what the domino effect would be,” says Asghar Rastegar, M.D., professor of medicine (nephrology) and associate chair for academic affairs. “This is sort of like a spring cleaning. Every room in the house had to be looked at.”

Institutions that skirt the new rules do so at their own peril. In 2002 the ACGME threatened to withdraw accreditation of the surgical residency program at Yale for violations of its previous duty-hours guidelines, and the accrediting board has come down hard on other elite programs since July 2003. Residency programs at Johns Hopkins, Duke and the University of Rochester have been subjected to similar “adverse actions” by the ACGME. However, just one year after the new rules took effect, Rosemarie L. Fisher, M.D., HS ’75, professor of medicine (digestive diseases) and director of graduate education at the School of Medicine, says that Yale has adapted well. According to Peter N. Herbert, M.D. ’67, HS ’69, chief of staff and senior vice president for medical affairs at YNHH, the close call with the surgical program’s accreditation may have been a blessing in disguise: the crisis led YNHH to take steps over the past two years—the Department of Surgery hired 12 physician assistants to lighten residents’ workloads, for example—that put Yale ahead of the curve for compliance.

Herbert says that problems arising from the new regulations may loom large at the moment, but he is confident that the rules will present few difficulties for Yale or for graduate medical education in general in the long run. “I think all of these concerns will be history in two or three years,” Herbert says. “We will find a way to educate our residents and to give them all the necessary experiences, in and out of the operating room, and at the same time take good care of patients.”

Education or service?

It has been a screenwriter’s staple since the earliest days of television medical dramas. A harried hospital resident, running on empty after yet another all-nighter, slinks into a darkened storeroom during an unexpected lull. The young doctor lies down and closes her eyes. But after just a few seconds of blessed sleep, the door bursts open—emergency! Cut to our rudely awakened heroine, who shakes off her drowsiness and rushes off to slay whatever dragon may await.

Any doctor knows that the relentlessly action-packed arena ofER only faintly resembles the everyday practice of medicine, but the stock character of the sleep-deprived resident is drawn from real life, and has been a familiar figure in hospital hallways for a century.

The punishing life of the resident, like many other features of graduate medical education in America, was a product of innovations in medical education made by William Halsted, M.D., a Yale College graduate who founded the vastly influential surgical training program at the Johns Hopkins Hospital during the 1890s.

For Halsted, who strongly admired the German medical system of his day, “residency” was literal: he required doctors in training to live at the hospital, and he discouraged his charges from marrying to ensure that they gave their all to the profession. His residency system combined the rigor of boot camp, the asceticism of the monastery and the esprit de corps of a college fraternity.

Senior physicians often speak of this system as if it had been in place since Hippocrates, but as Kenneth M. Ludmerer, M.D., professor of medicine and history at Washington University in St. Louis, says, residency was only one of many possible routes to medical specialization in Halsted’s time, and it did not become the dominant system in graduate medical education until the 1920s. Moreover, says Ludmerer, author of Time to Heal: American Medical Education From the Turn of the Century to the Era of Managed Care, residency was originally considered a privilege reserved for a few students who had demonstrated promise for an academic career, and a high attrition rate was considered a virtue.

“The concept was to start with a broad range of talented individuals, and of those, to select the very best,” says Robert Udelsman, M.D., M.B.A., Lampman Professor of Surgery and Oncology, chair of the Department of Surgery and chief of surgery at YNHH. This model was known as the “pyramidal system,” because fewer residents remained in a program each year; only those at the top tier survived to become senior or chief residents.

After World War II, several trends converged to “democratize” residency, vastly increasing enrollments in residency programs. An explosion in medical knowledge made specialization increasingly necessary, and there was growing pressure on faculty at teaching hospitals to provide clinical care while pursuing research. The availability of more residents to care for patients freed faculty for laboratory work, and residents took on more responsibility for teaching medical students. By the 1950s, grueling 100-hour workweeks had become the norm for residents, but the system was remarkably efficient and cost-effective. As Udelsman says, residents “worked like the devil, didn’t complain too much and saved hospitals a fortune.”

But according to medical historian Ludmerer, the educational mission of residency suffered greatly as hospitals increasingly relied on house staff for clinical care. “The dominant theme in the history of graduate medical education is the ongoing tension between education and service,” Ludmerer says. Graduate medical education still comes under fire for overemphasizing service and de-emphasizing education, a charge leveled since the 1930s, he says.

If anything, the devaluing of residents’ educational experience has only increased in the era of managed care—patients admitted to the hospital are far sicker and require more medical care than inpatients of a generation ago. Moreover, in the face of the recent nursing shortage residents have shouldered duties that have little or no relevance to the education of a physician. Because patient care must always take precedence over opportunities to teach medical students, medical school education has suffered as well. Nevertheless, Herbert says, arguments to reform residency to better meet educational goals have largely fallen on deaf ears, while the patient-safety crusade that grew out of the Zion case ultimately carried the day, leading directly to the ACGME’s restrictions on duty hours.

Unintended consequences

Like military service or athletic competition, enduring the trials of traditional residency has been a source of great pride and camaraderie for generations of physicians and has undoubtedly burnished the profession’s mystique in the public mind. But whatever its romantic aspects, the intense schedule of the medical resident had a purely practical benefit known as “continuity of care”: by treating newly admitted patients for long, uninterrupted stretches, budding doctors could see the natural course of disease and the effects of treatment unfold in ways no textbook could describe.

The new limitations on duty hours inevitably create breaches in continuity of care. Under the ACGME rules, residents must leave the hospital when their shift is over regardless of the clinical situation at hand, and the lack of flexibility in this regulation is the greatest source of dissatisfaction among both faculty and residents.

Robert J. Alpern, M.D., the Ensign Professor of Medicine (nephrology) and dean of the School of Medicine, says that “continuity of care was one of the best parts of the educational experience. Limiting continuity of care is especially bad for education because you learn about a patient much better if you follow them through their whole treatment.” Surgery chair Udelsman agrees. “I don’t think there’s any question that the residents are sleeping more, are home more, and I think they basically like that,” he says. “There’s also no question that they’re not getting as much exposure to patient care as they used to. There’s no getting around it.”

The same is true for medical students, whose schedules are tethered to resident teams’ shifts, says Herbert S. Chase Jr., M.D., professor of medicine (nephrology) and deputy dean for education at the medical school. “One learns by observing a patient live the natural history of an illness from beginning to end,” Chase says. “In the future, students are going to have to piece together the mosaic of a syndrome; they’re only going to see snippets of it. It will never be the same.”

But the advantages of continuity of care are not just educational. Though it might seem obvious that better-rested physicians will improve patient safety, Rastegar says that rigorous studies on this question in a medical setting are sparse and inconclusive. David J. Leffell, M.D., HS ’86, professor of dermatology and surgery and associate dean for clinical affairs, has similar concerns. “I don’t know if there’s any evidence that an 80-hour workweek is advantageous apropos risk,” says Leffell. “It seems like an arbitrary figure.”

On the other hand, there were some clear advantages to the traditional residency’s longer hours. For one thing, longer schedules meant fewer “handoffs” of patient histories and test results from one resident to another when signing out. Fisher used to warn residents to be especially vigilant about the possibility of medical errors during handoffs, which she says can come perilously close to the children’s game of “Telephone”—information passed from one person to another changes as it moves down the line. Though the pitfalls of handoffs are more subtle than resident fatigue and have largely escaped the notice of regulators, Rastegar says that two studies published in the 1990s in Annals of Internal Medicine and JAMA: The Journal of the American Medical Association presented convincing and worrisome data to back up Fisher’s concern. “There’s a trade-off between a rested team and handoffs,” he says. “Often handoffs have more negative impact on patient care than residents who have worked longer hours.”

Herbert says that some of these problems should diminish over the next three years as YNHH becomes an increasingly “paperless” hospital. “We need exquisitely tight signoff systems from caregiver to caregiver when we have so many more individuals involved in the care of patients,” he says. “The handoff with index cards and paper sheets is still going on, but there’s a lot of effort on computerized formats for doing signout, so any caregiver can go into the computerized medical record and see the major concerns and things that need to be followed up in patient care.”

Even as systems are put in place to alleviate procedural issues, many faculty worry that the new rules will create a “shift-worker” mentality in residents that will erode the absolute commitment to patient care so esteemed in traditional residency. Reports of residents at other institutions being physically forced to leave hospitals at the moment their duty hours end are troubling to those trying to instill absolute dedication to patients’ welfare at Yale. “Those are the residents you want to be your doctor when they leave,” says Leffell, “because they’re the ones who care the most.”

Meeting the challenge

Whatever the shortcomings of the new rules, those entrusted with implementing them are convinced that they are here to stay. Instead of greeting the ACGME ruling with a grudging passivity, Yale faculty and YNHH administrators have seized the moment to examine the fine structure of the residency system at Yale. Their ultimate aim is not rote compliance with the rules, but a reinvention of medical training that meets requirements but exceeds expectations in both education and clinical care.

For example, surgical volume is sharply up in Udelsman’s department, which has added 22 surgeons to the faculty in just the past two years. Because today’s hospital patients need a great deal of care, the reduction in resident duty hours has required junior faculty to perform many tasks formerly handled by interns; some assistant professors are logging in excess of 80 hours a week since the ACGME rules were enacted, Udelsman says.

His department has hired a dozen physician assistants to relieve residents and comply with the rules, but Udelsman suggests that tapping retired surgeons in the New Haven area would be a creative way to take up even more clinical slack. “What a waste to have these people sitting at home doing crossword puzzles when they could be in the operating room two or three days a week doing what they love to do,” he says. “It could be a win-win situation.”

In the Department of Internal Medicine a hospitalist service has been formed to care for an increasing number of patients who cannot be cared for by the medical house staff.

When it became clear that restrictions on duty hours were inevitable, Rastegar and his colleagues in the Department of Internal Medicine began to convene regular meetings of residents, chief residents and faculty to take a fresh look at house staff policies. “There was no blueprint to follow,” says Rastegar. “We had to develop it locally for our own hospital, and we knew we wouldn’t get it right the first time.”

They didn’t. A system in place last year was deemed unworkable and was jettisoned in favor of the current model, which is based on teams of two senior residents and two interns (first-year residents) under the watchful eye of an attending physician. Two medical students are assigned to each team.

One resident/intern pair in a team arrives for duty at about 7:30 a.m., working through the night and admitting new patients until 7:30 the next morning, when the other resident/intern pair arrives. The first pair is now deemed to be “postcall”; according to the new ACGME regulations, this pair may hand off patient care to the second team during rounds, but they may not admit new patients and they must refrain from any other clinical duties not crucial to continuity of care.

After rounds, which start at 7:30 a.m. and last until about 9 a.m., responsibility for the unit’s patients is in the new pair’s hands, and with the medical student’s help, the first team’s intern completes orders for tests and medications and any other paperwork. The postcall pair are also permitted to use any of their remaining six hours for conferences or other educational activities.

At 1 p.m., after a 30-hour shift, the first pair is officially off duty until the next morning’s rounds. Each resident/intern pair completes two such shifts per week, and puts in two days’ worth of more standard hours to approach the 80-hour maximum.

In the previous model, one resident supervised two interns, who could each admit five new patients and one patient transferred from another ward. Though interns can still admit the same number of patients, having two residents on the team should significantly improve both patient care and education, says Cyrus R. Kapadia, M.D., FW ’78, professor of medicine (digestive diseases) and director of the residency training program. “Now the resident has time to read more about a couple of his or her patients, and to spend more time teaching the intern and the medical student,” Kapadia says.

The ACGME has been unwavering in its enforcement of the 80-hour week, which faculty members say was probably necessary for hospitals to take the ruling seriously. And everyone agrees that they would much rather police their own programs in concert with the ACGME than submit to auditing by a government agency in the event that federal restrictions on duty hours were passed.

An unexpected gift

“House staff and trainees are probably more conservative than faculty,” says Fisher. “They’ll tell you all the time that they’d love to see change, but when it comes to making major changes, ‘Well, maybe you can do it next year, when I’m gone.’ ”

Perhaps, but Farshad Abir, M.D., a fifth-year administrative chief resident in surgery who completed the first two years of his residency before the new rules took effect, has no doubt that the ACGME-mandated changes are all for the better. “Just like anything in life, when you start something new you’re going to have kinks that need to be ironed out,” Abir says. “But I think definitely we’re moving in the right direction—100 percent.

“The way it used to be was awful,” says Abir, who regularly logged 120-hour weeks as a junior resident. The chance to straddle both systems has given him “perfect training,” he says, because having learned to budget his time under the old rules, he views the new workweek as an unexpected gift of 40 extra hours.

Surgery chair Udelsman would understand. Recalling his own resident days, he says, “I saw my kids at 11 at night when I got home. My wife would wake them up so I’d actually see them once in a while!” Udelsman believes that the traditional residency, whatever its strengths, created “abusive” physicians, and Herbert agrees: “You can’t treat physicians like work animals and expect that they’ll come out of it with correct attitudes,” he says. “I think in the end we’ll have more humane surgeons.”

Although Herbert’s YNHH desk sits squarely at the center of the fray in implementing the new ACGME regulations, he exudes confidence when asked about the future. “It’s a radical change for those of us who are members of the old guard, and we can’t believe that we can play on this field, but in fact we will play on it,” Herbert says. “Patient care will be as good, and education will be as good as well.” YM