There are limited data on working hours for psychiatry residents. While concern over work hours for residents in some medical specialties (e.g., surgery, medicine, obstetrics) has grown, psychiatry residents have largely been ignored in this debate, as their work hours have traditionally been more manageable. However, as the Accreditation Council for Graduate Medical Education (ACGME) enacts new guidelines on residents’ duty hours and working conditions, psychiatry residency programs, like all other residency programs, will have to adhere to the new guidelines. These guidelines mandate that: resident duty hours are limited to 80 hours per week; on-call assignments are limited to 24-hours per call, with up to 6 additional hours to transfer care of patients and educational activities; on-call shifts are limited to no more than one per third night; residents are to be off for 24 hours every 7 days; and a rest period of at least 10 hours between consecutive working days is required (1).
The policy has been introduced due to concerns over residents’ long working hours and the potential effect these hours on patient safety (2). From July 1, 2003, all ACGME-accredited residency programs were required to adhere to these new requirements or risk losing their accreditation.
The impact of these new guidelines on current practices of psychiatry residency programs is unknown. A search that we conducted on MEDLINE, PubMed, and Ovid did not produce any literature on working hours for psychiatry residents. Therefore, we researched trends in working hours for psychiatry residents to determine whether current practices in psychiatry residency programs might conflict with the new guidelines. In order to investigate this, we surveyed all psychiatry residency programs in the U.S. using a specially developed questionnaire.
Along with other senior faculty members, we identified four potential areas where the implementation of the new ACGME guidelines might prove difficult. Based on these potential problems, a questionnaire consisting of the following was developed: 1) Are the residents in your program working more than 80 hours? 2) Does your program require residents to attend clinical rounds on weekends if not on call? 3) Does your program require residents to be available by pager after hours when not on call? 4) Are residents in your program required to return to their clinical rotations after didactics?
All ACGME accredited U.S. general psychiatry residency programs (N=176) were contacted and invited to participate in our voluntary and confidential survey. The list of accredited psychiatry residency programs was obtained from the ACGME website (www.acgme.org). The survey was conducted in January of 2003 by e-mail, with subsequent phone and fax follow up with residency directors and/or program coordinators. The Creighton University Institutional Review Board reviewed and approved this study. Data were entered on SPSS (version 11) after being collected, and statistical analysis was performed using nonparametric Chi-squares tests.
A total of 176 general psychiatry programs were contacted and invited to participate in this survey. One hundred thirty one programs responded (approximately 75%). Ten programs refused to participate, and three of these programs returned a blank questionnaire that stated, "Our program adheres to all ACGME guidelines." A total of 121 programs agreed to participate in the survey. The survey questionnaire was completed by the residency program director, training coordinator, or chief resident. All programs (N=121) reported that their residents worked less than 80 hours per week. Approximately 78% of the programs (N=95) did not require their residents to attend clinical rounds on the weekends if they were not on call, while 21% (N=26) required their residents to attend weekend clinical rounds even when not on call (χ2 =39.347, df=1, p=0.0001). Furthermore, 70% (N=85) of the programs did not require their residents to be available by pager after hours when not on call, while 30% (N=36) required them to be pager available (χ2=19.843, df=1, p=0.0001). On the issue of requiring residents to return to the clinical service after didactics, 87% (N=105) of the programs designated didactic days (χ2=59.711, df=1, p=0.0001). Of these, 75% (N=79) required their residents to return to their clinical responsibilities, while 25% (N=26) did not (χ2=30, df=1, p=0.0001).
To our knowledge, this is the first study that examines current trends in work hours for psychiatry residents. Even though psychiatry has not been at the forefront of the debate over residents’ work hours, with the introduction of the new ACGME guidelines, several current practices of psychiatry residency programs might be affected. While the 80-hour/week limit will probably not affect any psychiatry residency program, except perhaps when residents rotate at other sites like primary care or neurology, other current work-hour-related practices may be in direct violation of the new ACGME rules.
First, the requirement of having a 24-hour period in a 7-day week free from all responsibilities might be violated if programs require residents to attend weekend rounds when not on call. In our survey, 21% of the programs reported that residents were required to attend weekend clinical rounds even if they were not on call. Residency programs might work around this policy by requiring residents to attend weekend rounds on only one of the 2 days (Saturday or Sunday). However, if a resident is on call the day before or after the weekend, requiring their presence during weekend rounds may still violate this rule. Further, even if residents are allowed time off for the entire day following weekend rounds, they generally are expected to return to work the next day at the usual time, which might not provide them the required 24 hours time off.
Second, the new rules allow residents to be on call for up to 24 hours, with an extra 6 hours for transfer of patient care and didactics. In our survey, 87% of the programs reported having scheduled didactic days. If postcall residents were asked to attend didactics on these designated days (which typically are scheduled from 8:00 a.m. to 3:00 or 4:00 p.m.), residents might have spent the 6 hours allowed before returning to complete their clinical responsibilities. Even if they were allowed to leave the didactics earlier, they still might not have enough time to attend to their clinical responsibilities. Further, the new ACGME guidelines specify that residents may remain on duty for up to 6 hours after completing a 24-hour on call period "for didactics and transfer of care responsibilities." It is not clear whether these standards include new patient evaluations in outpatient, inpatient, or consult services; if they refer to follow up of previous patients only; or if they refer to the transfer of care to other clinicians only. In our survey, 75% of the programs required residents to return to their clinical responsibilities after attending didactics. While our survey did not address this issue specifically for postcall residents, a stricter interpretation of the new guidelines might conflict with this practice if a program required postcall residents to attend didactics and then return to clinical responsibilities.
Third, the ACGME also requires that residents be given a minimum of 10-hours time off between consecutive working periods. Accreditation Council for Graduate Medical Education has defined "time off" as a period that is free from all residency-training requirements, "including clinical, administrative and educational activities." A stricter interpretation of this policy might conflict with another current practice of many residency programs that requires residents to be available by pager after hours, even when not on call. In our survey, 30% of the programs required their residents to be pager available after hours, even when not on call. Some respondents suggested that their interpretation of the new ACGME guidelines allows residency programs to expect their residents to be pager available, even during their 10-hour break. In our opinion, the new ACGME guidelines are not clear on this issue. Even if the pager availability was not counted toward duty hours, it might complicate matters for some postcall residents who complete the 24 + 6 hour shift but may still be required by their program to remain pager available.
These new ACGME guidelines pose a challenge for psychiatry residency program directors as they attempt to maintain the balance between the education and training of residents and adhering to ACGME guidelines. Supporters of weekend rounds and pager availability of residents argue that ACGME guidelines that restrict such practices might need to be reexamined, as these are usual clinical practices that ensure continuity of care to the patients and expose residents to the real world of psychiatric practice where practicing psychiatrists provide round-the-clock coverage for their patients. The availability of residents after hours might also have a quality of care and legal significance. Because residents are often most knowledgeable about their patients, they may be the best source of important clinical information needed in clinical situations that typically occur after hours. While the resident on call provides general coverage, certain clinical situations require a more in depth understanding of a patient and his or her treatment plan. These and similar situations might benefit from input by physicians who are most involved with a patient’s care. Restrictions placed on paging residents after-hours can deprive on-call residents and other clinical staff of input that may be invaluable. In cases when the lack of access to residents results in clinical error and a negative outcome, the policy of not contacting the resident, who may be able to provide timely input to avert looming crisis, might be difficult to defend legally.
These training and patient care issues must be balanced against the considerations that gave rise to the new ACGME guidelines. Increasingly, residents have been burdened with bigger caseloads of sicker patients (3). Furthermore, research suggests that sleep deprivation and lack of rest might compromise residents’ clinical decision making and educational performance (4—8). Additionally, public awareness of such potential problems has improved, leading to increased calls to regulate residents’ duty hours (9—11). Accreditation Council for Graduate Medical Education has been trying to influence residents’ working hours for the past 20 years. In 1980, the ACGME proposed that "hospital duties should not be so pressing or consuming that they preclude ample time for other important phases of the training program or for personal needs" (12). Because of worsening trends, new more explicit mandatory guidelines have been proposed. These newer guidelines, however, pose significant challenges to several current practices, only some of which have been addressed in this article. Further work is needed to assess the impact of the new ACGME guidelines on residency training. In the meantime, clearer interpretations of these new standards might help training directors in their efforts to ensure adequate protection of residents while ensuring appropriate education and training.
Although the ACGME has introduced explicit regulations to control worsening trends in residency training, further interpretation of these guidelines is required. Current practices of some psychiatry residency programs might conflict with the new ACGME guidelines. These programs may need to change those practices or recommend modification of the new guidelines for psychiatry. The goal of ensuring consistency in residency programs, avoiding exploitation of residents, and ensuring optimal patient care should not be difficult to achieve. More research is needed to determine whether these new regulations improve quality of care for patients and enhance the learning experience of psychiatry residents.
This study was supported in part by the Department of Veterans Affairs and the Robert Wood Johnson Foundation Program for Developing Leadership in Reducing Substance Abuse.