Before the 1980s, there was no restriction on resident physician work hours. The term resident was initially coined because physicians in training literally resided at the hospital. Then, in 1984, a fatal error occurred in a US teaching hospital. Eighteen-year-old Libby Zion died because of a lethal drug interaction that stemmed from a misdiagnosis of her symptoms.1 In the intense scrutiny that followed, their misdiagnosis was partly attributed to their exhaustion. Libby’s father was quoted in the New York Times as saying, “You don’t need kindergarten to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call — forget about life-and-death.”2 As a result, several legislations attempted to limit the number of residents' work hours to prevent burnout and resulting medical errors.
There is a need to consider the impact of these resident-hours regulations on various aspects of medical education and patient care. Most existing literature about this subject has focused on the role of fatigue in resident performance, education, and healthcare delivery. Yet, according to multiple reports, implementing workhour regulations did not reduce the risk of burnout. Ironically, fewer working hours seem to result in more burnout, potentially due to increased shiftwork. Residents’ decisions regarding patient care are strikingly different under the shiftwork mentality from those made under conditions of continuity. For instance, one study of interns concluded that trainees in the '16-hour duty' group admitted fewer patients and followed them up for shorter continuous periods. The study also documented the "strikingly low satisfaction of both nurses and residents with the quality of care provided by the '16-hour duty' group."3
It is possible that increased shiftwork in medicine can decrease ownership of treatment decisions and negatively impact the quality of care. When medical residents have a sense of decision ownership, they become personally invested in clinical decisions made for their patients. Decision ownership is the cognitive-affective phenomenon in which a medical practitioner develops a sense of responsibility over decisions about care for a particular patient and personal investment in this decision-making process.4 A feeling of decision ownership is tied to the individual need for efficacy as a healthcare provider. Ownership arises from relationships, and the more knowledge about the patient a resident has, the stronger will be their connection and ownership of that patient's care. Whenever something is owned, greater care, attention, and energy are poured into it. Therefore, feelings of decision ownership are induced by efficacy beliefs, familiarity with a patient's medical history, and self-investment in the given decision.
Having a shiftwork mentality and lack of decision ownership during residency can lead to diffusion of responsibility, focus on short-term benefits, and less chance of making interrelated choices associated with optimal long-term patient care. Diffusion of responsibility refers to the observation that the mere presence of other people in a situation makes one feel less personally responsible for the events that occur in that situation. Analogously, if an unidentified provider takes over their patient tomorrow, a resident may reason not to invest in their decisions as much as they would if they were following the case. If there is no way to identify their personal contribution, they may not be motivated to do their best and will tend to shift their responsibility onto some unspecified "other."
Decreased ownership may also lead residents to focus on short-term benefits and disregard future losses. In some treatment situations, the course of action that is most desirable over the long run may not be the best course of action in the short term. Ownership is more likely to occur when the consequences of many choices are considered rather than when each choice is made in isolation. Lack of decision ownership is like fighting one battle at a time without a guiding strategy. During their shifts, residents make more isolated decisions and are unlikely to have the opportunity to make interrelated choices in the ongoing care of a patient. Isolated decisions are problematic because residents cannot fully appreciate their consequences. When a resident makes these choices without thinking about their cumulative effects, that resident may make several apparently good choices which will collectively lead to a bad outcome.
There are several possible ways to foster ownership in medical residency while balancing resident wellbeing. Given the increased number of handoffs and resulting errors, one recommendation could be to make residents’ schedules more flexible by allowing longer work shifts but limiting weekly average hours and reducing their workload. Longer shifts will enable residents to follow the progression of a disease while reducing the workload will help to offset the risks of fatigue.
Over the past 20 years, teaching hospitals have seen a 46% increase in admissions and a concurrent increase in intensity of care per admission.5 Hour limitations mean that residents end up spending less time with each patient to keep up with an increased workload. While there have been many efforts to reduce resident fatigue and increase patient safety by limiting duty hours, less attention has been given to determining the levels of workload necessary for residents to become well-trained and to provide safe patient care. Training programs may need to change focus from work hour caps to measures of workload.
To mitigate handoff-related risks, one may suggest a more structured sign-out process that will include anticipatory guidance for predicted patient events. As the sign-out language can sometimes be vague, open-ended, and unstructured,6,7 there is a need for improvement in written sign-outs or increased use of verbal sign-outs. Finally, it is important for attending physicians to promote autonomous decisions by residents with proper support and supervision. Autonomy and perceived responsibility are critical elements of ownership and residents’ preparation for independent practice. While the focus should remain on patient safety, it is crucial to ensure that training programs adequately prepare residents to assume ownership of patient care in their future practice.
Alex Dubov, PhD
Dr. Dubov is an Associate Professor for the School of Behavioral Health. His research interests lie in applying scientifically rigorous approaches (i.e. conjoint analysis) to better understand and improve both patient and physician decision-making. He is also interested in leveraging emerging technologies as innovative approaches for supporting the implementation of combination (biomedical, behavioral, health system) interventions to prevent HIV infection among groups that are epidemiologically at high-risk for infection and whose prevention needs are complicated by their socially marginalized statuses in their communities
Asch, David A., and Ruth M. Parker. "The libby zion case." New England Journal of Medicine 318.12 (1988): 771-775.
Rosenbaum, Lisa, and Daniela Lamas. "Residents' duty hours—toward an empirical narrative." New England Journal of Medicine 367.21 (2012): 2044-2049.
Desai, Sanjay V., et al. "Effect of the 2011 vs 2003 duty hour regulation–compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: a randomized trial." JAMA internal medicine 173.8 (2013): 649-655.
Dubov, Alex, Liana Fraenkel, and Elizabeth Seng. "The importance of fostering ownership during medical training." The American Journal of Bioethics 16.9 (2016): 3-12.
Goitein, Lara, and Kenneth M. Ludmerer. "Resident Workload—Let's Treat the Disease, Not Just the Symptom: Comment on “Effect of the 2011 vs 2003 Duty Hour Regulation–Compliant Models on Sleep Duration, Trainee Education, and Continuity of Patient Care Among Internal Medicine House Staff”." JAMA internal medicine 173.8 (2013): 655-656.
Bump, Gregory M., et al. "Resident sign-out and patient hand-offs: opportunities for improvement." Teaching and learning in medicine 23.2 (2011): 105-111.
Nanchal, Rahul, et al. "Controlled trial to improve resident sign-out in a medical intensive care unit." BMJ Quality & Safety 26.12 (2017): 987-992.