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APPD Action Team
Executive Summary
Re-Engineering the Resident Job

Marc Majure, Mary Ciccarelli, Christina Master, and Samuel Seward

Any industry that operates on a 24/7 basis has fatigue; we cannot make it go away. Therefore, we need to learn to manage fatigue. Goals to this end might include: 1) decrease resident patient care hours; 2) enrich educational content to make efficient use of the time available for educational activities; and 3) strengthen institutional support to provide an infrastructure in which goals 1 and 2 can be accomplished.

Given the inevitable expectation that we will all be living under the new duty hour guidelines starting July 1, 2003, we must plan how to accomplish the goal of duty hours while maintaining all of the other ACGME mandated program requirements: competency-based training, progressive independence within supervisory guidelines, and continuity. Therefore, we cannot think of a reduction in duty hours as simply a form of downsizing; we are actually being asked to re-engineer the job description of the resident physician.

In general, there are 4 ways in which a job can be re-engineered:
Eliminate the task.

Assign the task to someone else

Shift time priority in a reorganization of timeliness of tasks.

Reallocate time allowing some tasks to be done at resident's discretion

Suggestions for re-engineering the job:

Perhaps one of the simplest solutions is to look at what tasks resident physicians are currently performing that they do not need to do (or perhaps could be combined with another task). This is slightly different than assigning the job to someone else, but rather looking to see if a task might be redundant or simply a hold-over because "that's the way it's always been done." Some rounds or conferences are potential examples of this. The gathering of morning data such as vital signs, ins and out, calories, labs can be streamlined through improved computer informatics systems which collect data in a readily available manner.
The second step that generally comes to mind is asking if someone else could do the job. Phlebotomy is a common example. Many institutions feel that pediatric phlebotomy requires skills beyond that of a phlebotomist that would be appropriate for an adult floor and, therefore, have reduced phlebotomy services for pediatrics with residents filling in the gaps. Some institutions utilize pediatric nurses, rather than residents. The further complexity of the service/education dyad is that changes in the system must also avoid rebound effects which impair residents from acquiring the skill they do actually need in venipuncture, as well. Resident physicians often spend inordinate amounts of time scheduling procedures or even transporting patients. Non-teaching hospitals are often structured with a higher level of systems' efficiency in scheduling or providing reports back to the ordering private physicians. Teaching institutions may need to take some examples from other hospitals. Transcribing data from one source to another, i.e. the inpatient chart to the discharge paperwork is another task that may be electronically-automated. Other institutions have employed "carve-outs" of patient populations to shift responsibility of care to the attending service rather than care being part of the resident service. Examples of such patient populations include post-heart catheterization patients, post-biopsy observation patients, bone marrow transplant patients, sleep study patients, and patients undergoing extended pH probe testing. Night coverage with such "carve-outs" can present a unique problem if residents are required to provide coverage at night on patients for whom they do not provide care during the day and for whom the service attending may not attend sign-out. Finding new mechanisms to simplify or incorporate sign-out of these patients is an important issue.
Shifting time priority to reorganize the timeliness of tasks may improve flow during the day and increase resident efficiency. However, this is often a difficult undertaking because of the multiple stakeholders for whom schedules need to be taken into account. While it would be desirable to look at the task flow during the day and schedule conferences, etc. during times of low patient care responsibility for the residents, that time for the attending leading the conference may be a high demand time. Perhaps a more feasible solution would be to give a higher priority to making residents aware of tasks in a timely fashion which will give them the best ability to organize their workday, e.g. notifying the resident team of an admission early in the process to give them the option of coming to clinic to see the patient rather than waiting for the patient to arrive on the ward or anticipating discharges so that discharge paperwork might be completed as much as possible prior to the last minute.
One of the biggest pieces of the residents' day is scheduled conference time. Taking residents out of patient care to allow uninterrupted time for didactics has a watershed impact on the day; however, didactic time is paramount to the educational process. A proposed solution would be to make some didactics available as web-based modules that residents can complete at their discretion. While web-based training can be used to augment the educational process, it should not be used to replace the bulk of the didactic curriculum. Residents desire the camaraderie of conference time and the spontaneous interaction of group discussion will always enhance any learning experience. Unfortunately, the 24+6 hour rule will narrow the window of opportunity for rescheduling some of the conference time.
Faculty who traditionally bring the full resident team to each patient's bedside daily may need alter their rounding style by choosing which patients would be the best teaching cases to include the team at the bedside while holding other discussions in a conference room, so that all the time faculty spends in discussions with patients and families does not require all the residents to be in attendance.

Perhaps even more difficult than changing the number of hours worked will be changing the culture. Residents will differ in their response to these changes; faculty members will certainly have an opinion. All of this will come from a change that will be brought about in a mere few months in the backdrop of a culture that has been defined over decades. This will not be an easy task!!

While general guidelines can be proposed, the re-engineering of the resident job will necessarily be institution specific. Regardless of what the Program Director feels is the best design for the local program, implementation remains one of the biggest hurdles to overcome. Suggestions to help a Program Director approach implementation within the local institution include the following:

The key to change is the development of a new attitude based upon the philosophy of the program. This philosophy must reflect a balance between the service needs of the institution with the educational goals of the Training Program. Broad support for this philosophy must be sought. Hospitals may not be allowed to maintain the traditional level of dependence on resident service.
Obtaining broad support will require involvement at all levels of the institution

Resident input is paramount to the process as they must feel that their views have been heard.
Administrators must be involved early on in the process and will (most probably) need some education on the process and requirements of Graduate Medical Education.
Faculty members will need to be encouraged to see beyond their own service needs.

One method to accomplish this might be to develop a Division Liaison Committee to engage the Division impacted by the changes as a group so that they can hear from their colleagues how these changes impact the mission of the Department as a whole.

Nursing and ancillary services must be involved in the process because changes in the residents' day will impact their day.

Ancillary services, e.g. nursing, continually face providing continuing education (in-service training) to their employees while dealing with overlapping shifts, hour constraints, and may have worthwhile suggestions.

The process of delineating local changes and obtaining support for the recommended changes needs to be started early and needs to be continued with contact within the working group at frequent enough intervals for the group to see progress and to not get discouraged.

Many programs are hosting weekly meeting with faculty and residents to discuss change within the program.

While the emphasis in this process is reduction in duty hours, the ACGME-mandated competencies must not be forgotten. In particular, the competency of professionalism becomes increasingly difficult to portray to learners in an environment driven by number of hours. Proposed changes must include some avenue to instill a professional work ethic in trainees.

Specific suggestions for implementation include:

Exam the use of geographic teams (larger, but more complex, more built-in cross coverage by virtue of team size) vs. service/subspecialty teams (smaller, single subspecialty-focused, less inherent cross-coverage by virtue of smaller team size)
List all important daytime tasks and figure out which pieces could be farmed out to a floating clerk such as the famed "Mr. Judd" at Hopkins
Consider an Evening Report in night float systems to facilitate learning and transition of care
Use hospitalists who are present at night to provide educational component during night float hours

Conclusions:

Start the process EARLY
Involve all stakeholders, particularly residents
Examine the tasks and activities that residents currently perform
Educate and involve administrators early
Attempt to describe and define the IDEAL TRAINING ENVIRONMENT
Make sure that there is a clear philosophy and that all are understanding the philosophy to make a shift in attitude - from what will impact service to what will support the philosophy
Is it necessary to "carve out" patients?
Is the problem the 80 hours or the daytime continuity post-call?
Examine conferences and when they should occur
Remember to gain knowledge from nursing staff and other institutions
Do not lose sight of the professionalism issue

References

Schulman M, Lucchese KR, Sullican AC. Transition from housestaff to nonphysicians as neonatal intensive care providers--cost, impact on revenue, and quality of care. American Journal of Perinatology. 1995; 12:442-446.

Gottlieb DJ, Parenti CM, Peterson CA, Lofgren RP. Effect of a change in house staff work schedule on resource utilization and patient care. Archives of Internal Medicine. 1991; 151:2065-2070.

Knickman J, Lipkin M, Finkler S, Thompson W, Kiel J. The potential for using non-physicians to compensate for the reduced availability of residents. Academic Medicine. 1992; 67:429-438.