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Invited Commentary
April 22, 2013

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”

Author Affiliations

Author Affiliations: Division of Pulmonary and Critical Care, Christus St Vincent Regional Medical Center, Santa Fe, New Mexico (Dr Goitein); and Department of Medicine, Washington University School of Medicine, St Louis, Missouri (Dr Ludmerer).

JAMA Intern Med. 2013;173(8):655-656. doi:10.1001/jamainternmed.2013.740

Work compression is doing the same amount of work in fewer hours. The term is often used to describe an effect of the restriction of residents' work hours by the Accreditation Council for Graduate Medical Education (ACGME). But before work hour limitations were implemented in 2003, residents were already experiencing work compression. From 1990 to 2010, annual admissions to major teaching hospitals increased by 46% (Katherine Brandenburg, Association of American Medical Colleges, written communication, December 11, 2012), while first-year residency positions, limited by restrictions in Graduate Medical Education funding, grew only 13%.1 During the same period, length of stay fell by almost one-third, and intensity of care per admission greatly increased.2 In short, by the time ACGME restrictions were implemented, residents were already doing much more, in less time and for more and sicker patients, than were previous generations of house staff.

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    1 Comment for this article
    A Medical Student Perspective
    Corey J. Hiti | University of Miami Miller School of Medicine
    Comment on: Resident Workload—Let's Treat the Disease, Not Just the SymptomA Medical Student PerspectiveAs a fourth year medical student on the verge of graduation I feel that it is important to point out that the working environment experienced by residents can, and does, affect the learning environment medical students experience while on their core clinical clerkships dramatically. The apprenticeship model that is the core of medical training begins in the clinical clerkship years, with medical students learning from faculty, but predominantly from their residents, how to function in a clinical setting. Learning how to perform an accurate and thorough history, perform physical exam maneuvers, and interpret laboratory and imaging data are processes fundamental to becoming a skilled physician and require the time and patience of a skilled instructor to communicate them to the newest physicians of tomorrow.Besieged by increasing time pressures and workloads, with few incentives to teach medical students beyond compassion and a genuine desire to teach, would it be surprising to find that residents have less time to educate medical students? In a recent article, Kogan et al1 investigated how work hour restrictions impacted internal medicine clerkship experiences by surveying medical students and clerkship directors both before and after the implementation of duty-hour restrictions. They found that, while clerkship students felt that attendings and interns provided effective teaching, clerkship directors disagreed that interns, residents, or attendings had more time to teach and most felt that students received less feedback from interns or residents during their clerkship. The frightening conclusion that one may draw from this study is that today’s medical students are receiving a poorer quality education while simultaneously being completely unaware of it. While the issue of medical education is certainly more complex than outlined above, I would suggest that even the most well-intentioned residents may find it hard in today’s practice environment to dedicate the time they’d like to educating their younger colleagues. Without these early educational experiences, the apprenticeship model of medical education is severely undermined starting from the clinical clerkship years, not solely beginning in residency. Residents are not only tasked with the bulk of patient care duties in University care settings, but they are also educators of the next generation of physicians and the first role models medical students will experience in their journey towards becoming a physician. Their value to the education of medical students should not be overlooked in assessing the impact of workload compression on the medical profession.1. Kogan JR, Lapin J, Aagaard E, et al. The effect of resident duty-hours restrictions on internal medicine clerkship experiences: surveys of medical students and clerkship directors. Teaching and learning in medicine. 2015;27(1):37-50.