• 1.

    Philibert I, et al.; ACGME Work Group on Resident Duty Hours; Accreditation Council for Graduate Medical Education. New requirements for resident duty hours. JAMA 2002; 288:11121114. doi: 10.1001/jama.288.9.1112

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Bolster L, Rourke L. The effect of restricting residents’ duty hours on patient safety, resident well-being, and resident education: An updated systematic review. J Grad Med Educ 2015; 7:349363. doi: 10.4300/JGME-D-14-00612.1

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Rosenbluth G, et al. Association between adaptations to ACGME duty hour requirements, length of stay, and costs. Sleep 2013; 36:245248. doi: 10.5665/sleep.2382

  • 4.

    Theobald C, et al. The effect of reducing maximum shift lengths to 16 hours on internal medicine interns’ educational opportunities. Acad Med 2013; 88:512518. doi: 10.1097/ACM.0b013e318285800f

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Pivert KA, et al.; ASN Data Subcommittee. 2023 ASN Nephrology Fellow Survey. American Society of Nephrology; September 27, 2023. https://data.asn-online.org/posts/2023_fellow_survey/

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Sen S, et al. Effects of the 2011 duty hour reforms on interns and their patients: A prospective longitudinal cohort study. JAMA Intern Med 2013; 173:657662; discussion 663. doi: 10.1001/jamainternmed.2013.351

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Barger LK, et al. Impact of work schedules of senior resident physicians on patient and resident physician safety: Nationwide, prospective cohort study. BMJ Med 2023; 2:e000320. doi: 10.1136/bmjmed-2022-000320

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Drolet BC, et al. Compliance and falsification of duty hours: Reports from residents and program directors. J Grad Med Educ 2013; 5:368373. doi: 10.4300/JGME-D-12-00375.1

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Healthcare Cost and Utilization Project (HCUP). HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2009. Agency for Healthcare Research and Quality (US); 2011. https://www.ncbi.nlm.nih.gov/books/NBK91986/

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Naik H, et al. Population-based trends in complexity of hospital inpatients. JAMA Intern Med 2024; 184:183192. doi: 10.1001/jamainternmed.2023.7410

Improving Nephrology Education: Beyond Duty-Hour Restrictions

Alexis Gomez Alexis Gomez, MD, is a nephrology and pediatric nephrology fellow at Massachusetts General Hospital, Brigham and Women's Hospital, and Boston Children's Hospital in Boston, MA.

Search for other papers by Alexis Gomez in
Current site
Google Scholar
PubMed
Close
Full access

There is a growing movement, particularly in the United States, focusing on enhancing wellness initiatives for trainees at various levels across all specialties. Notable adjustments include reduced call hours, more weekends off, and dedicated study leave. Although these changes have received praise, there is some concern among educators regarding potential unintended consequences, such as less effective training and lack of preparedness for an attending position after graduation. To gain insights into the impact of these initiatives on trainees’ well-being and education, Kidney News Editorial Fellows asked both a current fellow and a program director to provide their opinions on the matter.

Over the past few decades, there has been a growing focus on trainee well-being. Starting with duty-hour restrictions in 2002, efforts are now expanding to focus on reducing call burden, increasing weekends off, protecting didactic time, and factoring in other wellness initiatives (1). Seemingly every program within and outside of nephrology has put trainee wellness under a microscope. Of course, with these initiatives comes the chorus of outcries that training necessarily suffers.

Understanding why there is mixed evidence surrounding the impact of duty-hour reductions on trainee experience and education is essential to knowing how best to proceed. For example, a systematic review published in 2015 of studies on duty hours concluded that there was no difference with respect to the impact on patient care. Yet, it should be noted that many studies in the review showing no impact or a negative impact examined surgical residents, for whom extended shifts may have been necessary for interns and residents to see a surgery through to completion (2). In general, outcomes are more neutral to positive in studies focused on internal medicine or pediatric residents. Various studies found improvements in patient length of stay when trainees’ hours were reduced, with others demonstrating an improved breadth of notes, an increasing volume of patients, and a greater likelihood of conference attendance (24). Additionally, over half of nephrology fellows report frequency of weekend and overnight calls as “extremely important” when evaluating job offers, indicating that reducing the number of these shifts does have an impact on wellness and quality of life (5).

Still, results are not always consistent, and the reasons for this are varied. For example, shifting to night float is not always accompanied by a concerted effort to include night-float trainees in didactics during their shifts, resulting in decreased educational opportunities. Other studies report results on statistically significant yet functionally meaningless reductions in duty hours, including one study published in JAMA Internal Medicine in 2013 in which the authors concluded harm in duty-hour restriction with a reduction of fewer than 3 hours per week (6). In contrast, another study with more significant reductions found much more positive results when looking at errors and preventable adverse events (7). Perhaps most importantly, with the large volume and increasing complexity of patients seen in many training hospitals in recent years, simply attempting to enforce a reduction in hours without adjustments to address workload compression results in trainees feeling forced to either falsify hours (with one report finding nearly half of residents falsifying hours) (8) or to provide substandard care due to these time restrictions (9, 10).

In my experience as an internal medicine and pediatrics trainee across nine different hospitals over the past 7 years, I feel this last issue of workload compression is most pertinent. I have found that many decry training these days as inadequate for independent practice, and the most cited reason is hour restriction. To many pushing this narrative, so too is my generation often described as a “lazy” one, seemingly endlessly wanting more personal time without considering whether we are adequately prepared. We are deemed in a perpetual state of adolescence, unable to accurately self-assess preparedness, rather than as stakeholders in our own adult education.

Yet, with the number of patients steady or increasing and the complexity of encounters on the rise, a generation of educators should ask themselves why they see a generation of physicians they deem unprepared for practice (9, 10). Although a minimum number of encounters are undoubtedly necessary, without addressing work compression, trainees increasingly find themselves unable to debrief patient encounters with attendings and to learn from missteps to care for each patient better as we advance. As we strive to take better care of patients, with inadequate time to do so, education is the only thing left to steal time away from in the day. I find that few, if any, trainees are willing to provide subpar care to protect this time.

When faced with this reality, program responses are varied. For example, some programs carefully assess the number of encounters and time needed to train in chronic rather than acute dialysis and limit this to the necessary minimum. Others choose to use trainees as the sacrificial lambs for the inevitable 6 a.m. pages managing patients with chronic stable dialysis in lieu of learning opportunities on general or subspecialty consults, leaving us inadequately prepared to manage these patients going forward.

Fellows must be treated as important educational stakeholders and adult learners. Programs must consider not only the concern that we may be falling short but also our input on why this may be occurring. To address these issues, it is time for educators and program leadership to go back to the drawing board and overhaul fellow education, focusing first on adequately preparing us for the future rather than using us for adequate hospital staffing.

Footnotes

The author reports no conflicts of interest.

References

  • 1.

    Philibert I, et al.; ACGME Work Group on Resident Duty Hours; Accreditation Council for Graduate Medical Education. New requirements for resident duty hours. JAMA 2002; 288:11121114. doi: 10.1001/jama.288.9.1112

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Bolster L, Rourke L. The effect of restricting residents’ duty hours on patient safety, resident well-being, and resident education: An updated systematic review. J Grad Med Educ 2015; 7:349363. doi: 10.4300/JGME-D-14-00612.1

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Rosenbluth G, et al. Association between adaptations to ACGME duty hour requirements, length of stay, and costs. Sleep 2013; 36:245248. doi: 10.5665/sleep.2382

  • 4.

    Theobald C, et al. The effect of reducing maximum shift lengths to 16 hours on internal medicine interns’ educational opportunities. Acad Med 2013; 88:512518. doi: 10.1097/ACM.0b013e318285800f

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Pivert KA, et al.; ASN Data Subcommittee. 2023 ASN Nephrology Fellow Survey. American Society of Nephrology; September 27, 2023. https://data.asn-online.org/posts/2023_fellow_survey/

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Sen S, et al. Effects of the 2011 duty hour reforms on interns and their patients: A prospective longitudinal cohort study. JAMA Intern Med 2013; 173:657662; discussion 663. doi: 10.1001/jamainternmed.2013.351

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Barger LK, et al. Impact of work schedules of senior resident physicians on patient and resident physician safety: Nationwide, prospective cohort study. BMJ Med 2023; 2:e000320. doi: 10.1136/bmjmed-2022-000320

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Drolet BC, et al. Compliance and falsification of duty hours: Reports from residents and program directors. J Grad Med Educ 2013; 5:368373. doi: 10.4300/JGME-D-12-00375.1

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Healthcare Cost and Utilization Project (HCUP). HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2009. Agency for Healthcare Research and Quality (US); 2011. https://www.ncbi.nlm.nih.gov/books/NBK91986/

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Naik H, et al. Population-based trends in complexity of hospital inpatients. JAMA Intern Med 2024; 184:183192. doi: 10.1001/jamainternmed.2023.7410

Save