Implementing Resident Work Hour Limitations: Lessons From the New York State Experience

Abstract

New York State has had residency work hour regulations for 15 years, and, since 1998, a strong effort to enforce these rules has been made. This study examines the impact of implementation of these rules on residency training, the quality of residents' lives, and patient care. Data were gathered with a carefully constructed questionnaire sent to all surgical residents in the state, including senior residents in their final year (n = 1037). Three hundred nineteen questionnaires were returned. Respondents felt their residency programs generally complied with the regulations and that support and enforcement were growing. Twenty-five percent reported stricter enforcement following an inspection that resulted in a fine for violation of regulations. Also, 19% noticed stricter enforcement after an adverse patient outcome, a site visit, or other event. Both residents and their residency programs reported a mean of 88 hours worked per week (range, 11-140 hr). The schedules reported by junior and senior house staff and by community and academic hospitals were in general agreement. Most residents said they took in-house calls no more frequently than every third night. Calls were taken from home more often by senior residents (16.7% vs. 4.7% for juniors; P <.05) and by those in academic programs compared with community hospitals (14.3 vs. 4.7%; P <.05). Respondents reported that hospitals used various strategies to cover night call, including night floats, increased cross-coverage, and increased use of nurse practitioners and physician assistants. Nearly 3/4 of the residents thought that, in general, the regulations were a good thing. Sixty-four percent and 66%, respectively, of participants said that with the implementation of the regulations they felt more 'well rested and that their quality of life outside the hospital was improved. Less than half, 42%, felt the quality of their work life inside the hospital was improved. A total of 33.4% senior residents and 28.2% academic residents reported a negative impact of regulations on their work life compared with 19.3% of junior residents and 20% of community hospital residents (P <.01 for both). Senior house staff were more likely to feel that the reduction in work hours left them with the burden of much of the scut work that once was the juniors' respponsibility (79.2% of seniors vs. 34.9% of juniors, P <.01). Overall, 71% of the residents from community hospitals more frequently reported a reduction in work hours (81%) than those in academic centers (66.4%, P <.05). Twenty-two percent of respondents said that the overall quality of resident training had improved whereas 35% felt the regulations had resulted in a decrease in the overall quality of their training. More time for reading and studying was noted by 47% of residents. However, 50% reported participating in fewer operations, and 51% said that they hail missed too many learning opportunities under the new regulations. These sentiments were more likely to be expressed by senior residents and residents in academic medical centers than by junior house staff or those in community residencies.