Attendings’ Workload, Duty Hours, and July, Oh My!

By Lisa Roshetsky, MD, MS, assistant professor of clinical internal medicine, Medstar Georgetown University Hospital, and Vineet Arora, MD, MAPP, assistant dean for scholarship & discovery, University of Chicago Pritzker School of Medicine

Every July, as academic hospitals welcome new interns, a flurry of activity ensues. While learning to care for patients and navigating the complex social territories of their new hospitals, interns also are worrying about “getting out on time” and making sure not to “dump” on their colleagues. This work compression, particularly among interns who are not familiar with the day-to-day operations of wards, can strain the learning environment. With the implementation of resident duty hours regulations, attending physicians are subsequently called to provide more direct patient care. Yet residency is a time for learning on the job, and part of that learning comes from the teaching attendings provide. In our recent study in Academic Medicine, we asked: “So what has happened to time for teaching?”

Given the recent changes in academic medicine, attendings’ workload needs to be examined, especially regarding their role as teachers. Previously, most studies of workload and work compression focused on residents. Moreover, these studies commonly focused on workload as it related to patient census. While patient census is one measure of workload, we all have had the experience of how one very complicated patient can add up to more work than 10 relatively straightforward patients. So, should we instead consider perception of workload rather than actual workload measured by volume?

Borrowing from methods developed at NASA to examine astronauts’ workload, we examined attendings’ perceptions of workload and the relationship of those perceptions to reporting enough time for teaching. In doing so, we found a steep relationship between attendings’ greater perceived workload and time for teaching. Additionally, we analyzed our results with respect to the time of year and to the implementation of duty hours regulations. Implementing duty hours regulations, not unexpectedly, reduced attendings’ time for teaching, but the magnitude of this reduction was humbling.  What was most surprising, however, relates to the time of year, specifically summer, which everyone fears because of the “July effect”.  Interestingly, more teaching occurs during summer than during winter and spring. We also found that attendings’ greater workload during winter and spring was more detrimental to their time for teaching than their workload during summer.

Certainly, having attendings provide more direct care when residents have heavy workloads improves patient safety. However, the cost to residents’ education and subsequent learning and growth is not trivial. Ensuring that teaching on the wards is restored should be a central focus of graduate medical education reform.  Moreover, while winter and spring should be times for continued teaching on advanced topics to ensure professional growth towards achieving competence, for some reason, we fall short. Meanwhile, during summer, attendings may cut back on their own busy clinical practice and/or administrative duties in anticipation of their role as teachers and supervisors. Regardless of the reason, to prepare for future changes to the accreditation system and attendings’ role in documenting progression through milestones, testing and implementing innovative ways of re-balancing workload to restore teaching and learning on the wards is imperative.

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7 Comments

  1. From Astronauts to Attendings: Workload, Duty Hours and July, Oh My! | FutureDocs
    July 31, 2013 at 3:20 PM

    […] reposted from Academic Medicine’s blog […]

  2. Kemi Tomobi
    July 31, 2013 at 10:26 PM

    July is indeed a time of transition at nearly every stage of medical training and practice.  It is also the time when a lot of teaching is done.  Fourth year medical students have the opportunity to teach and guide freshly minted 3rd year students, especially if the 4h years are pursuing a Subinternship in a specialty of interest at this time, so it is an opportunity to show leadership skills and function as an intern.  As for others who are higher in the hierarchy,  there is much teaching and learning to be done.

    So if students want to position themselves for the best learning experience from attendings, and if there are many residents around, as in a major academic center, then the best time to schedule such a rotation would be in the summer months so students can at least get secondhand learning.  I, however, am still a fan of the smaller hospitals with fewer or no residents, so there is more opportunity for one on one learning and a more representative summary of one’s performance and potential for future practice.

    The role of attending as teacher is crucial.   Having more attending presence around not only improves patient safety, it improves student learning safety from tired, overworked residents, and students can feel like they will learn something from an expert on the floors. If the attending is sound in educational theory (perhaps with further leadership and training in the practice of education, such as with a masters in education) and applies it to teaching, then the quality of teaching will be better, and residents and attending will be better able to balance teaching with the workload.  Most attendings do not have this educational “masters” exposure and are still great teachers, but to improve healthcare, there are still issues in graduate and undergraduate education that can be changed, and academic leaders with a sound background in educational training, theory, and practice will help pave the way for better medical education training and thus, better healthcare for patients.

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  3. Kemi Tomobi
    August 1, 2013 at 12:07 AM

    I would just like to add that I look forward to these discussion rounds and journal club discussion topics. It helps spark my interest in academic medicine and in ways one can improve the way physicians are trained. I really appreciate these opportunities.

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    • Journal Staff
      August 1, 2013 at 12:20 PM

      We are glad to hear it, Kemi! That was precisely what we had in mind when we launched AM Rounds, and we appreciate your continued interest in and engagement with our content.

  4. Vinny Arora
    August 2, 2013 at 3:20 AM

    Thanks for a thoughtful comment. I agree certainly that faculty development in this area for attendings is critical! Here we have a faculty development program, but are also extending it to residents through a medical education track for our GME programs.

  5. Shannon K. Martin (@ShannonMartinMD)
    August 4, 2013 at 9:46 PM

    Thanks Vinny and Lisa for highlighting an important issue facing inpatient teaching physicians following the most recent duty limitations. Duty hours have diminished the amount of time that teams have together – attending rounds may be the only extended period of time that that the inpatient team is able to be together, and this time period has become much more patient-care centered in order for the attending to ensure the team is providing safe patient care. As the previous commenter astutely noted, faculty development in teaching methods is absolutely essential to educate our future physicians and ensure the best patient care. I would add that teaching under the duty hours limitations must also be reimagined and reconceptualized to take advantage of alternative methods and strategies that can optimize learning under the duty hours limits. Technological advances, the explosion of social media and health care, and learning preferences of the current generation of trainees can empower us as teaching attendings to approach teaching on the wards in a variety of different ways, which may mitigate some of the time limitations imposed on the traditional attending teaching rounds structure.

    We have highlighted a number of teaching strategies to reconceptualize teaching on today’s wards which we recently shared in the Journal of Hospital Medicine. Our proposed model, “FUTURE”, prompts attendings to approach teaching rounds with an eye for innovation by Flipping the Wards, Using Documentation to Teach, Technology-Enabled Teaching, Using “Guerrilla” Teaching Tactics, Rainy Day Teaching, and Embedding Teaching Moments in Rounds. (Martin, S. K., Farnan, J. M. and Arora, V. M. (2013), FUTURE: New strategies for hospitalists to overcome challenges in teaching on today’s wards. J. Hosp. Med., 8: 409–413. doi: 10.1002/jhm.2057 http://onlinelibrary.wiley.com/doi/10.1002/jhm.2057/full)

    Thanks again for starting this important discussion and I look forward to hearing about others’ experiences!

  6. wsumed
    September 6, 2013 at 2:10 PM

    Reblogged this on WSU MED.