Background:
As further limits in resident duty hours are considered, anecdotes of detrimental effects of work intensification (same amount of work in less time) and the continued reliance on residents for tasks of limited educational value (“scut”) are prominent. The aim of this study was to systematically review the literature to examine how residents spend their time and to assess the impact of workload and work solutions on resident education and patient care.
Methods:
In consultation with a biomedical librarian, We conducted an electronic search of the English literature in Medline and Embase from 1989 to 2009. We exploded more than 20 Medical Subject Heading terms related to workload, work, work environment, and so forth. Workload terms were combined with multiple terms for “graduate medical education” and “residency” Each study was abstracted into an online Research Electronic Data Capture (REDCap) database. To assess study quality, the previously validated Medical Education Research Quality Index (MERSQI) was used (range 5–16, mean 10).
Results:
The search yielded 4805 articles, of which 54 met inclusion criteria. Overall, the 21 studies examining resident time allocation suggest that at least one third of resident time is spent on activities of limited educational value. Eight of the 9 studies evaluating the impact of resident workload on patient care (mean MERSQI 12.5) showed a negative impact on outcomes including length of stay, mortality, patient satisfaction, medication errors, and lab utilization. All 8 studies (mean MERSQI 11.0) that examined the impact of workload on resident health (sleep, fatigue, and markers of physiologic stress) or resident education (test scores, learning styles, participation in educational activities) were negative. Sixteen studies demonstrated successful offload of resident tasks to other staff (physician extenders, hospitalists, etc.). Studies indicated that offsetting workload may enable residents to take advantage of more educational opportunities (e.g.,, attending conferences), Drawbacks of offloading tasks to other staff included confusion about role of nonresident staff, high turnover, and cost.
Conclusions:
A significant fraction of resident time is of limited educational value. Excessive workload has a negative impact on resident education and patient care. Workload solutions, such as hospitalists and physician extenders, can improve resident learning without affecting patient care. As further limits in resident duty hours are debated, optimal workload and work activity for residents should be considered to maximize learning and patient outcomes. However, given the negative impact of workload, future studies to define optimal hospitalist workloads should be undertaken.
Author Disclosure:
V. Arora, ACGME, ABIM Foundation, ACP Foundation, AHRQ, NIA, grant funding; D. Reed, ACGME, ABIM, grant funding; K. Fletcher, ACGME, VA, grant funding