Education and patient care effects of resident workload restrictions: tackling a largely unexplored subject.

The need to set limits on residents' workloads was mentioned as early as 1989, concurrent with the early efforts to set duty hour limits.1 In 2012 the subject of residents' workloads is still underresearched, but studies have shown that although practicing physicians' work hours declined in the late 1990s, duty hours for residents actually increased during the same interval.2 The exact causes of this surprising effect are not known, but likely contributing factors were high patient census and clinical intensity and the effects of the Balanced Budget Act, which restricted the number of residents that institutions could admit to their training programs. The Accreditation Council for Graduate Medical Education (ACGME) established common duty hour requirements in 2003. This intervention unintentionally compressed patient care demands into fewer hours, preserving or even increasing workload in many instances, simply because fiscal constraints forced many institutions to continue a heavy reliance on residents' clinical contributions.3 As described in this issue, Thanarajasingam et al4 tested an intervention to reduce the workloads of internal medicine residents and assess the effect on duty hour compliance, participation in didactic activities, and patient safety in teaching settings. They explored the benefits of caps on patient load and unit-based admissions on objective measures of resident workload. Specifically, they found meaningful improvements in 2 key educational metrics: duty hour compliance and ability to attend conferences. Both of these metrics address the frequently stated assumption, supported by research, that residents stay beyond their allotted duty hours or miss scheduled didactics because of pressing clinical work.5,6 The intervention of Thanarajasingam et al also resulted in a nearly statistically significant improvement in a clinical measure of workload appropriateness: rates of 30-day patient readmissions to the resident service. Residents have reported high workload and work intensity as contributing factors in medical errors.7 Similar research in nursing has found that work intensity is associated with a higher risk for medical errors, especially when there are frequent work interruptions and “multitasking”—attributes equally relevant to the residents' working environments.8 The intervention of Thanarajasingam et al consisted of 2 components: census caps (limits on the number of patients and the number of admissions for a given resident or team) and unit-based admissions. Both likely result in real amelioration of residents' workloads, although for different reasons. Unit-based admissions address the distribution of clinical work across the hospital and the required added effort. The most trivial and well-studied component may be miles walked,9 and the most potentially harmful and largely unstudied aspect may be the patient safety implications of subtle differences in the systems of care and approaches for “getting things done” across units. Standardizing the work environment is a classic systems engineering approach to enhance patient safety10 and may be even more important when learners participate in care.