Over the past decade, in response to public concerns about medical errors arising from fatigue, the Accreditation Council for Graduate Medical Education, the organization responsible for accrediting American medical residency programs, has been progressively limiting the number of hours that trainees can work. The latest mandate, which took effect in 2011, is the most stringent and deals most specifically with interns. These youngest doctors are allowed to work no longer than 16 hours in a day; and residency programs that violate the restriction risk losing their accreditation.

In response to the 16-hour mandate and faced with a Rubik’s-cube conundrum of covering all the work with the same number of interns working fewer hours, training programs across the country came up with several innovative scheduling configurations. Some created complicated and overlapping shifts where outgoing doctors “signed out” their patients, passing off their responsibilities to the incoming shift. Others adopted a “night float” system that meant a resident just a year out of internship had to carry the work of as many as 12 interns at night, looking after more than 100 patients and fielding questions about those patients at best every 20 minutes and at worst every 11 minutes throughout the night.

Now, two years after the 16-hour mandate was established, studies on the outcomes are being published, and the results reveal one thing.

Maybe we should have thought a little harder about the arithmetic.

Contrary to expectations, these studies have shown that interns have not been getting significantly more sleep. Moreover, they are not happier, nor are they studying more. In one national survey, nearly half of all doctors in training disapproved of the regulations altogether. Another study revealed that interns were spending less time in educational activities because the additional time required for such conferences and lectures would push them over the 16-hour limit.

In addition, there has been no significant improvement in the quality of care since the work limits took effect. In one case, doctors had to scrap the night float system because the nurses thought the care offered by trainees on that schedule was so poor. Another study revealed that interns confessed to having more concerns about making serious medical errors after the mandate than before.

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Medical interns spend just 12 percent of their time examining and talking with patients, and more than 40 percent of their time behind a computer, according to a new Johns Hopkins study that closely followed first-year residents at Baltimore's two large academic medical centers. Indeed, the study found, interns spent nearly as much time walking (7 percent) as they did caring for patients at the bedside.

Compared with similar time-tracking studies done before 2003, when hospitals were first required to limit the number of consecutive working hours for trainees, the researchers found that interns since then spend significantly less time in direct contact with patients. Changes to the 2003 rules limited interns to no more than 30 consecutive hours on duty, and further restrictions in 2011 allow them to work only 16 hours in a row.

"One of the most important learning opportunities in residency is direct interaction with patients," says Lauren Block, M.D., M.P.H., a clinical fellow in the Division of General Internal Medicine at the Johns Hopkins University School of Medicine and leader of the study published online in the Journal of General Internal Medicine. "Spending an average of eight minutes a day with each patient just doesn't seem like enough time to me."

"Most of us went into medicine because we love spending time with the patients. Our systems have squeezed this out of medical training," says Leonard Feldman, M.D., the study's senior author and a hospitalist at The Johns Hopkins Hospital (JHH).

For the study, trained observers followed 29 internal medicine interns—doctors in their first year out of medical school—at JHH and the University of Maryland Medical Center for three weeks during January 2012, for a total of 873 hours. The observers used an iPod Touch app to mark down what the interns were doing at every minute of their shifts. If they were multi-tasking, the observers were told to count the activity most closely related to direct patient care.

The researchers found that interns spent 12 percent of their time talking with and examining patients; 64 percent on indirect patient care, such as placing orders, researching patient history and filling out electronic paperwork; 15 percent on educational activities, such as medical rounds; and 9 percent on miscellaneous activities. The researchers acknowledge that it's unclear what proportion of time spent at the bedside is ideal, or whether the interns they studied in the first year of a three-year internal medicine training program make up the time lost with patients later in residency. But 12 percent, Feldman says, "seems shockingly low at face value. Interns spend almost four more times as long reviewing charts than directly engaging patients."

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For years, medical students who chose a residency in radiology were said to be on the ROAD to happiness. The acronym highlighted the specialties — radiology, ophthalmology, anesthesiology and dermatology — said to promise the best lifestyle for doctors, including the most money for the least grueling work.

Not anymore. Radiologists still make twice as much as family doctors, but are high on the list of specialists whose incomes are in steepest decline. Recent radiology graduates with huge medical school debts are having trouble finding work, let alone the $400,000-and-up dream jobs that beckoned as they signed on for five to seven years of relatively low-paid labor as trainees. On Internet forums, younger radiology residents agonize about whether it is too late to switch tracks.

At St. Barnabas Hospital in the Bronx, a dozen radiologists in training, including Dr. Luke Gerges, 28, are suddenly stranded on an expensive road to nowhere. All received termination notices recently because their hospital is ending their residency program next year as part of a plan to replace its radiologists with a teleradiology company that reads diagnostic images remotely.

“Those days of raking in the dough with radiology are gone,” said Dr. Gerges, who is four years beyond medical school and $300,000 in debt. He said he chose a specialty he loves without caring that big salaries were waning, but never imagined it would be this hard to finish his postgraduate training and get a job.

“No one is going to hire me to be a radiologist without my training,” he said.

Few specialties have been immune to the same factors depressing radiology: deep Medicare cuts, cut-rate competition driven by technology, doubts about the health value of many tests and procedures and new measures to tilt public money to primary care.

The case of St. Barnabas may be extreme, said Dr. Paul H. Ellenbogen, chairman of the American College of Radiology, the principal organization of the nation’s 30,000 radiologists, who called the hospital’s treatment of the residents “unconscionable.” But it is part of a larger pattern that has made radiology the target of a dozen cuts in Medicare reimbursement since 2006, he said, totaling $6 billion.

“We were somewhat victims of our success,” said Dr. Ellenbogen, in Dallas, whose career spans what radiologists call the golden years, when the cost of diagnostic imaging grew faster than other items in health care.

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Giving residents less time on duty and more time to sleep was supposed to lead to fewer medical errors. But the latest research shows that’s not the case. What’s going on?

Since 2011, new regulations restricting the number of continuous hours first-year residents spend on-call cut the time that trainees spend at the hospital during a typical duty session from 24 hours to 16 hours. Excessively long shifts, studies showed, were leading to fatigue and stress that hampered not just the learning process, but the care these doctors provided to patients.

And there were tragic examples of the high cost of this exhausting schedule. In 1984, 18-year old Libby Zion, who was admitted to a New York City hospital with a fever and convulsions, was treated by residents who ordered opiates and restraints when she became agitated and uncooperative. Busy overseeing other patients, the residents didn’t evaluate Zion again until hours later, by which time her fever has soared to 107 degrees and she went into cardiac arrest, and died. The case highlighted the enormous pressures on doctors-in-training, and the need for reform in the way residents were taught. In 1987, a New York state commission limited the number of hours that doctors could train in the hospital to 80 each week, which was less than the 100 hour a week shifts with 36 hour “call” times that were the norm at the time. In 2003, the Accreditation Council for Graduate Medical Education followed suit with rules for all programs that mandated that trainees could work no more than 24 consecutive hours.

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Over the past thirty years, video games have become omnipresent in American popular culture. Children and adults alike get involved in gaming for entertainment and social engagement, as well as to take part in learning opportunities as varied as the technology itself. Reading primers are brought to life with colorful graphics and catchy, cartoon-filled comprehension exercises; guitar techniques are divulged by the hottest rock musicians; and precise hand-eye coordination is mastered by the surgeons of tomorrow. The latter is made possible with the help of not the latest console, but rather with game-inspired virtual reality (VR) laparoscopic surgical simulators.

Today’s surgical residents are tech-savvy. Indeed, they're more than likely to have a gaming console at home: according to a 2012 Neilson study, 56% of American households own an X-Box 360, Nintendo Wii, Playstation 3, or similar current generation gaming platform. And so residents are predisposed to appreciate the possibility of training through game-based simulation. VR laparoscopic surgical simulators allow residents to develop motor skills, including tool usage, dexterity, and carpal range, within a software program. During a training exercise, residents use realistic laparoscopic instruments to manipulate virtual objects by following along on a computer monitor. A wrong move immediately prompts the program to notify them through visual or physical cues, enabling understanding and correction of skill deficiencies.

Like video games, VR laparoscopic surgical simulators encourage users to practice until they receive a high score. Residents can complete exercises repeatedly, move on to higher levels requiring more skill and expertise, and see how they rank in comparison to their peers. It becomes an appealing – and even fun – challenge to master the virtual laparoscopic program and rank locally, regionally, nationally, and beyond. And because increasingly advanced educational tracts may be available, residents will always be motivated to continue their training.

Laparoscopic surgical simulators also give residents the opportunity to develop skills in a safe environment. They're free to make mistakes – and learn to improve on them – without running the risk of harming an actual patient. And when it's time to perform an actual laparoscopic procedure, they'll have clocked many hours of training, making them better able to perform at a higher caliber from the start.

Gaming technology can lead users into new worlds, help them unlock artistic potential, and sometimes even educate them in a specialty as delicate, attention-demanding, and intense as surgery. When coupled with traditional surgical training program curricula, laparoscopic surgical simulators allow residents to develop their skills – and have fun in the process.

Major changes are coming to the nation’s medical residency programs. The Accreditation Council for Graduate Medical Education (ACGME), the nonprofit organization that evaluates and accredits more than 9,000 medical residency programs in the United States, has announced it will transform how these programs will be accredited in the years ahead.
 
As described in an article published in the March 15 issue of The New England Journal of Medicine (Nasca TJ et al. 2012;366:1051-1056), the ACGME’s next accreditation system (NAS) for graduate medical education is centered on six domains of clinical competency, developed in concert with the American Board of Medical Specialties. In an interview, the article’s lead author, Thomas J. Nasca, MD, chief executive officer of the ACGME in Chicago, characterized these domains as “patient care and technical skills; medical knowledge; professionalism; interpersonal communication; systems-based practices; and practice-based learning and improvement.” Dr. Nasca stated that the NAS “is the culmination of a decade’s worth of work building consensus around the competencies.”
 
The difference between the past accreditation system and the NAS, said Dr. Nasca, is that the new system will evaluate educational outcomes rather than just processes, and the core or essential educational outcomes will be standardized for each specialty. To distinguish between a process standard and an outcome standard, Dr. Nasca gave the following example: “There must be simulation training in induction of anesthesia” is a process standard; “The resident demonstrates effective incorporation of knowledge and skill in the administration of anesthesia” is an outcome standard.
 
In July 2013, seven of the 26 ACGME-accredited core specialties will implement the NAS. The seven specialties are emergency medicine, internal medicine, neurologic surgery, orthopedic surgery, pediatrics, diagnostic radiology and urology. In July 2014, the remaining specialties will apply the NAS.
 
Dr. Nasca detailed some of the projected benefits of the NAS. Residents will be reassured that all programs teach and evaluate the same desired outcomes, with a “more targeted evaluation of performance, and more effective formative feedback—a focus on what is essential.” The program directors will get a less intrusive ACGME, with decreased administrative burden, giving them time for more mentoring and direct education. The public will be the “ultimate beneficiary,” because it will get better-trained physicians.
 
“It’s not just an educational exercise,” said Dr. Nasca. “We will reassure the public of the completeness of the training and that each graduate has demonstrated the core skills required in their chosen specialty, prior to entering clinical practice in the profession.”
 
According to Christine Stencel, spokesperson at the Institute of Medicine (IOM), the National Academies, Washington, D.C., “The new accreditation system is consistent with recommendations of the IOM’s 2003 report Health Professions Education: A Bridge to Quality.”
 
When asked about the IOM’s view of the NAS, Ms. Stencel pointed to a study of the governance and financing of graduate medical education that the IOM will begin conducting in June 2012. “The committee for that study will likely take up aspects of the ACGME accreditation reported by Dr. Nasca in The New England Journal of Medicine. IOM cannot prognosticate on what this related new study will conclude and recommend and therefore must withhold any judgments.”
 
A comprehensive article about the ACGME’s NAS will appear in the May issue of Gastroenterology & Endoscopy News.

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