 I'm delighted to welcome you all to today's professionalism meeting. We're so happy that Dr. Vinnie O'Rora will join us to speak today. Dr. O'Rora is an associate professor of medicine and an associate program director of the internal medicine residency program. She's also an assistant dean for the program on scholarship and discovery at Pritzker. As many of you know, those of you who have heard Dr. O'Rora speak at other times and have worked with her, her academic interests focus on, broadly, improving the learning environment for medical students and medical residents and on improving the quality of care that we provide to patients. She's published on topics such as the care of elderly hospitalized patients, medical professionalism, sleep deprivation, the handoff problem as residents rotate and pass on the care of patients to others. Today, and I love this topic, today Dr. O'Rora is going to speak on a wonderful topic. It's called the good old days, evidence of old world professionalism in modern day residency trainees. Vinnie. As we talk about resident duty hours, which is really one of the most contentious topics I think I've ever spoken about, I expect to inspire some controversy in the room and inspired by other talks that I've been at that have ended controversially. I hope to also equally end controversially. Let's see, does this work? The outline for today's talk is, as given in the title, we're going to talk about the old world definition of professionalism and how that meets the challenges of the new world. I'm going to focus specifically on residency training, but some of what I described certainly applies to the students and the audience, especially those fourth year students, including my advisees. You better turn in your rank list tonight, it's due today. So the challenges of the new world with shift work mentality. And then I want to specifically focus on data that we've collected, three specific stories that highlight resident work ethic with work hours. So how are residents really handling this tension between old world professionalism and the challenges of the new world? And I hope to end with some, the need for an evolution and a dialogue about professionalism as it relates to residency trainees. So some of you probably can recite this by heart, including me and some of my colleagues, but I know that the ethics conference draws a large audience, and so I just wanted to highlight some background, quick background of how we got here with residency duty hours. And so in 1984, Libby Zion, who is the daughter of Sidney Zion, who is a powerful editor and involved in the New York Times, his daughter died in a New York hospital, an academic New York hospital, of a preventable adverse event. And in investigation of that event, Dr. Bertrand Bell was asked to chair a blue ribbon panel titled the Bell Commission that issued a report. And on the top of that report, they examined all of the root causes that led to her death. And I'm not going to get into the specifics, but it's a fascinating story. The number one thing that actually was cited was inadequate supervision of residents and interns in the night who were making medical decisions. And then later on in their 18 comments that they made, they also highlighted fatigue and resident fatigue because they were working very long hours. Needless to say, the things that got picked up from that report and translated into policy really focused on fatigue and very little until recently has focused on some of the other areas. And so this led to 1989, the New York State Code 405, this is the Department of Health Code, actually revision to state that residents could no longer work more than 24-hour shifts in New York. And that was implemented early in New York, which then led to congressional demands for investigation of this issue. One of the most powerful people who would advocate for this is Representative Conyers, which then led the ACGME, the Accreditation Council of Graduate Medical Education, which is located here in Chicago and accredits residency programs under the threat of federal pressure to regulate duty hours by first mandating an 80-hour work week as well as a maximum shift of 30 hours for residents. And this was done in 2003, which is the year after I finished my chief residency, which was pivotal in my research and educational career. And between 2003 and 2008, we were under the system of the 2003 duty-hour regulations. And I'm going to show some data about how people responded to the duty-hour regulations during this time. But then because the 2003 rules still called for shifts of up to 30 hours, which were considered marathon shifts, the community of sleep researchers as well as patient safety advocates were very effective in lobbying Congress to reconvene folks to investigate this issue. And so on behest of Congress, the Institute of Medicine actually investigated the issue and issued a report on resident duty hours, actually stating that all residents should work no more than 16 hours. So needless to say, the responses from medicine to the Institute of Medicine report were very vocal and uniformly negative. And there were letters and a variety of different petitions sent to the ACGME calling for more robust evidence than what existed, as well as delay of any standard implementation based on the Institute of Medicine report. So I do want to highlight what do patients think in all this, because this is a question that sometimes is asked, and I know as the McLean Center often thinks about doctor-patient relations, what do patients think about this? Well, it's hard to get your handle around that question, but there is a website called wakeupdoctor.org, which is actually a website of 40 patient advocacy groups that claims to represent the public. And so often when Congress wants to know what the public feels, they'll go to this website. And they highlight on their website, new research finds that only 1% of the general public supports widespread practice of resident physicians working shifts longer than 24 hours. This was a telephone survey done by Harvard sleep researchers that is somewhat contentious for a variety of reasons, because when they ask the public on the phone whether or not they would like their doctor to work 24 hours, it was led by a prologue that said currently the residents are working very long hours, and it didn't highlight any of the trade-offs or the consequences of having a doctor who's unfamiliar with their care. And most people can understand being tired is bad, and so you can understand why nobody wants to have a tired doctor. They also go on to use a little bit of sensationalism. You've seen them on scrubs, ER, and Grey's Anatomy, deeply fatigued interns and residents, but truth is stranger than fiction. So I highlight the difficulty in getting the actual public to weigh in on this issue. So under the threat of federal regulation, once again, the ACGME actually in 2010 issued their new recommendations for DD hours. And this is the paper that was issued in the New England Journal of Medicine by Tom Nasca, who's the current CEO of the ACGME and his colleagues. And one thing that was interesting is they actually issued a rule that was somewhat controversial. Instead of adopting the IOM's recommendations for 16 hours for all residents, they actually examined the data and heard reams of testimony. And the 16-hour study is actually based on one study done in a Harvard ICU of a group of under 20 medical interns. And so that is the data for which we have a 16-hour that shows that attentional failures and medical errors went up in the group that was working longer than 16 hours. And so they decided to institute a 16-hour shift for PGY1s only, because that's where the data existed. But to continue to allow PGY2s and above to work a marathon shift 24 plus four hours, they shortened it slightly. And the idea being that there was still this concern of resident experience. They also issued a few other recommendations related to night float and strategic napping. And so since then, the dialogue regarding resident duty hours, I mean, we could talk all day and all night about whether the ACGME should or should not restrict duty hours or whether, you know, what we feel about it. But the truth of the matter is I think all of us have realized in medical education that duty hours are here to stay. And it is a part of the culture now of residency training. And so a more nuanced question is how does duty hours affect the evolving dialogue around professionalism? Well, to answer this question, it's important to go to the literature. And actually, it was at this conference that I was introduced to this diagram, which is part of Fred Haferty's work on professionalism and highlights the seven competing clusters of professionalism. And one of those clusters, the first cluster is nostalgic professionalism. And so in nostalgic professionalism, the values that are weighted are autonomy, altruism, professional dominance, social contract and social justice at the expense of things like lifestyle. Now, another competing cluster and the one that I'm going to talk about the most is called, is dubbed lifestyle professionalism, which Haferty and colleagues actually state this is the new generation of what our trainees espouse to be, to have healthy balance and espouse lifestyle professionalism. So while autonomy is still valued, things like lifestyle and personal morality actually outweigh things like the social contract and social justice. So whether or not you agree with what these competing clusters are, I will highlight that the responses that you have regarding duty hours and that the community has around duty hours do frame nicely with this nostalgic versus lifestyle competing clusters. So this is actually what I would dub the nostalgic response. And this is actually seminal work that was published by an old friend of our institution, Charles Bosk, who actually with Kevin Vope at the University of Pennsylvania and two graduate students embedded themselves at the University of Pennsylvania watching residents as they were carrying out their duties to better understand, do residents have shift work mentality? Do they look at the clock? Do they want to leave? And what are the kind of issues that they face? And in their study, they reviewed a lot of faculty responses as well. And so they highlight some faculty responses, which I would argue are the nostalgic response. Residents feel like more like clocked employees, less like professionals. It's not my patient. We've heard that quite a bit. We have diminished a profession that took great pride in total devotion to patient care to one where the time clock rules whether to finish a task, the patient be damned. So really strong opinions. You also hear about people describing this competing cluster of lifestyle in a very negative way. 80-hour work weeks in residency will make lifestyle an important consideration for these individuals. They will be less inclined to make themselves available for emergency call in hospitals and less likely to choose rural or solo practice. Obviously, that has major policy implications in the setting of the Affordable Care Act and a nationwide shortage of physicians. Now, those were just some excerpts from one institution. So what do people think around the country? And so Darcy Reed and colleagues have actually surveyed key clinical faculty in internal medicine over the phone regarding duty hours. And in a big study that they looked at regarding the impact of education, they also specifically asked about resident professionalism. And in all four domains that they looked at, accountability, ability to place patient's needs above self-interest, the resident-patient relationship, and resident professionalism overall, you see that the faculty were more likely to report a decrease that they believed that duty hours were decreasing resident professionalism. And this study was done actually shortly after the implementation of the 2003 duty hours. Now, do we have more recent data? Well, I'm actually part of the Aptum Survey Committee, which surveys all internal medicine program directors on a periodic basis, and duty hours is one of their favorite topics. And so we ask similar questions. And from the 2009 data representing a big chunk of program directors in internal medicine, we see that most internal medicine program directors strongly believe that professional ownership of patients decreases with resident duty hours. So we see some data that suggests that faculty leaders involved with training and program directors are really concerned about resident professionalism in the setting of duty hours. And so one question that I've been struggling with is, have residents truly embraced lifestyle professionalism? And if so, how have they done that? And so to answer this question, again, we go to the literature. And what's interesting in a study done by Nida Ratan-Wagusa and colleagues at Johns Hopkins University is that she highlights that actually residents continue to value the old world professionalism values, like altruism, self-awareness, most of the principles they actually place a very high importance on to their practice. The challenge that they face is actually putting those principles into daily practice. So they have this tension, they want to adhere to these values, but they have a problem putting them into practice. And here's a great example from this study of why do they have this problem. I would like to spend as much time as I felt needed informing patients, families with diagnoses, tests, especially new diagnoses. But sometimes I need to cut short the discussion as I need to get out or finish my work, though I feel like this is part of my work, so really expressing the tension. Now, also in this study, they specifically asked residents about duty hours and professionalism. And what's interesting is that at least some of the residents highlighted that they thought duty hours did indeed affect their professionalism. So similar to the quote that we just saw, less time to talk with patients or families, time pressure in general, continuity was reduced, and professional accountability as well. But there was also a similar fraction that thought that resident duty hours would promote professionalism. So the lifestyle argument, less fatigue, more teamwork, personal well-being, being less tired. And so the lifestyle response was echoed in this study by a variety of individuals that said residents feeling toxic leads to poor professionalism, grumpy lack of sympathy, not wanting to take time for shared decisions with patients, thus better rest leads to more professional behavior. And another resident, being overworked and tired makes it hard to act graciously. And I think most of us can also agree with these comments as well. Now, that was simply one institution again and one group of residents. And that was also done shortly after the resident duty hours. And so interestingly, there's been little data nationwide from residents. We've surveyed program directors a lot. We've surveyed faculty a lot. But then the question is, what do residents really think about this issue? Now, we were fortunate to partner with the American College of Physicians. They administer the in-training exam that actually goes to all residents in the fall of their residency. And on that in-training exam, we're embedded some questions regarding duty hours that were asked of the program directors. And so with Elizabeth Pasch, who's one of our hospitalist fellows here, we've been analyzing some of this data, which comes from over 12,000 residents. And what's interesting is that it's not as easy to say, okay, all residents are concerned about professionalism. There's actually some interesting variation where PGY3s express greater concern about the impact of duty hours on professional ownership than PGY2s and PGY1s. And so one thought there is perhaps that they're more entrenched in the old version of training. And when this came out, they're still clinging to the nostalgic professionalism. Now, the other argument could be maybe they know more and they know the untoward effects of duty hours. But interestingly, there's some other interesting findings that we're still teasing out. And I just want to highlight that it's not an easy story. So U.S. medical grads are also more concerned about duty hours than international medical grads. And this may be the case because many other countries have already limited duty hours, although some of the most common pipeline countries that send residents to this country actually do not have limits. So it's still a little bit unclear. Another competing explanation is that international medical grads who are concerned about saying anything negative about the program or giving up their spot may not want to say anything negative about resident duty hours. And so interestingly, and this is more hot off the presses, residents who are graduating out of university-based programs are also more concerned about the effect of resident duty hours on professionalism than those in community programs. And that may speak to specific tensions that those of us in university hospitals face. And then there's something different about the Northeast than the rest of the country. And I don't know what it is, but I think a big explanation could be that New York has already had duty hours for a very long time. And so those in New York, which actually holds one quarter of all residency spots in the nation, so they're a powerful block. So the New Yorkers may be driving this and they may say, oh, it's not that big of a deal. We've had it for a while. And that may speak to the fact that perhaps with time maybe people will feel differently about how resident duty hours affect this. Also, a lot of international medical graduates in that New York cohort. Yes, and even these, I should add that these associations hold up even when controlling for the others. So have residents embraced lifestyle professionalism? Well, so far in my review, I have not seen any conclusive evidence that they've completely embraced it, and they still demonstrate high professional accountability towards patients, and moreover, they express a grave concern about duty hours. And what's perhaps the most interesting is that those that are further along in residency express greater concern than those who are just beginning residency. So now moving on to the next example that I want to highlight, which is one of the big concerns with shift work mentality or lifestyle professionalism is people will literally become watching the clock and leaving the hospital. So my next question is, do residents do this? Watch the clock and leave the hospital on time. And you can probably guess what the answer to this is, but I want to take you through an interesting article about what we have forced residents to do, which is this leave or lie quandary. We now force them to leave a patient with whose treatment they are intimately involved or to cease learning in this example, surgery, midstream. And one of my favorite quotes is although we have added professionalism as a training goal, we gave our trainees the choice between abandoning a patient and lying. And so faced with these two choices, what do they do? And so my first question is, do residents lie? And in fact, in studies, roughly 50% of U.S. surgical trainees in one study have reported lying about duty hours. Obviously, it's difficult to collect this type of data, but I do want to highlight that we are not alone. So the European Union, which actually mandates a 48-hour work week for its residents or junior doctors, and actually I should say it mandates a 48-hour work week for everyone, all workers, which is why I think we should move there. But has actually been in place now for some time, and this is policed by their health service. And actually, here's a headline from their news, like from their CNN. NHS urging junior doctors to lie about hours to comply with EU laws. And this is not alone. Multiple scandals have been reported where EU physicians, junior doctors are basically being told by the hospital to just make it sound like you're working under 48 hours. Or there have been other creative solutions. For example, when David and I visited Ireland, I was surprised to learn that when I talked to the residents that they were there all day and all night and working more than we were, in fact, more than our residents were, and that they were having the same issues. And I said, well, what about these European Union laws? And they were like, oh, yeah, that's by the UK. And, you know, those guys are soft. Here in Ireland, we're tough. And every country has a different response. And our country's response is to say that there are service hours and there are educational hours. And that's acceptable. And so we have 48-hour service hours and there are only educational hours. And so I highlight that not everything is as it seems. So the next question is, do residents leave the hospital? And this is easy data to look at because we can look at compliance with the ACGME rules. Now, the best data we have is actually a nationwide study that was done the year after the implementation of the 2003 rules by Chris Landrigan and colleagues at Harvard. And Chris Landrigan is the same one that led the 16-hour ICU study that looked at intentional failures and medical errors. And in this nationally representative sample of residents, he would ask them by month to report on logs, you know, how often they exceeded their duty hour limits. At the time, this was the 80s hour and the 30 hour. And what's interesting is that the 80 hour was rarely violated. It was more often the 30 hour rule that was violated. But as you can see, it was roughly half reporting every month and with maybe a slight trend by when it was first introduced. And if you take it all together over the year, 88% of residents reported that they had gone over their hours at some point. Now, you might be interested to know that during the same time, non-compliance with duty hours reported by the ACGME, or to the ACGME, I should say, was 3%. And so you might be wondering, how is there such a big difference? And obviously, residents may have been more honest with the researchers in this study than they are on the ACGME survey or to the ACGME. But the other thing is it's also the method that's important. The method by which the study measured non-compliance was any non-compliance, any shift, any time you went over, which is a very high bar. And when you ask people at the ACGME who actually police duty hours, you know, what do they think about this, they will actually tell you that they're more concerned about the average. And then the way they ask the questions on the survey is, how often are you exceeding your duty hours? So there is the idea that there could be an exceptional case where you need to stay and there's something going on that requires attention. But if it's a minor thing that only happens once, it's not going to get counted. And so in order to put programs under, to say programs are non-compliant, they very much have to be violating duty hours on a consistent basis. Now the discrepancy between 88% and 3% or 50% no matter how you cut it is still very large. And so there's probably still some element of not truthful reporting going on. So why do residents not leave? So this is actually in the discussion of this paper, but I will also add we can all add our own anecdotal experiences. I myself have personally escorted residents out of the hospital. It happens actually more often in July or August. It seems to be more common with residents than interns. But why is that? Well, the first is maybe a systems issue. Which is that we do not yet have systems in place for residents to depart on time due to a variety of barriers. The ACGME mandates are unfunded. And so how are hospitals going to meet those demands? Who is going to pick up the work? Are residents going to just abandon their work when the clock ends? And more importantly, have we really tested workload to meet the work shifts that we've created? I'm not going to show the data, but in data we have actually reviewed elsewhere using some of our own data collected here. If an intern admits five new patients in a 24-hour period in July, they are universally always going to violate the 30-hour rule. Now this was before the 16-hour rule went in place. And that was the cap. So we've set them up to fail five admission cap. So one question is, should we adjust the system to design shifts where residents are successful and can leave on time? And oftentimes what Tom Naska at the ACGME always says is, you know, in medicine we schedule everyone to the max. We schedule everyone to leave at 1 p.m. And if they leave at 1 p.m. it doesn't give them proper time for a handoff. And if the new person is coming at 1 p.m. you already know the person is not going to leave until 1 p.m. or 2 p.m. Now that's one issue. And the systems issues I think we're, you know, they're going to take time to solve and people are working on them. But the harder issue to solve is professional culture. Which is, is there this implicit desire for faculty willing them to stay or saying, oh, back in my day. And so perhaps they're getting this message that, you know, it's strong work to stay. And I will tell one story about my own residency, which was when I had a patient, one of our patients who my intern called me and said, this patient on the HEMOC service is having the worst headache of their life. And I thought, okay, that's really not a usual way to describe a headache. So we went to go evaluate the patient. And having said that he had the worst headache of his life, this was now 5 o'clock and we were preparing our sign out, of course. And we were on call the next day. And so we decided to stay and work up the patient, wheeled them ourselves to get a non contrast head CT which was positive for subarachnoid hemorrhage. So then we called neuro vascular angiogram. And then neurosurgery, the patient went to neurosurgery to get their aneurysm clipped. So I walked out of the hospital and went to the parking garage. I think sometime after midnight to come back at 7am to start my call in which there was no 30 hours. And I had called my attending, who was Dr. Olapati. And the next morning when I arrived my intern came in a little bit late because she was obviously tired. And we had started rounding. And my attending, Dr. Olapati looked at me and she said, strong work. And so I knew I had done a good job. Now this was back in the old days. And so I highlight that to think when I heard that I thought okay, I'm horribly tired but I did it. And so another follow up to this story is that I actually saw the patient who later was in the ER with one of his family members and he remembered me. So this was a year later I saw him and he was like, thank you for saving my life. And so there are those moments in medicine where you do stay because there is the patient in front of you that needs help. Now the key though is, so what do we do? Are house staff unwilling to leave? Is it the faculty that are kind of sending this message? Or is it the house staff at that setting like we chose personally to be like we're not signing this over to cross cover. We're going to stay and work this up. Now this is a question that I've explored with some of our residents here back in 2003 shortly after the initial duty hours went into place. And what we did was we gave residents the opportunity interns the opportunity to have night float coverage for protected sleep time. And this was a time when everyone was deciding should residents work shorter shifts or should we try to provide naps in the middle of shifts so residents can continue to provide continuity of care the following day. So using our paging system we were able to download paging logs and find out when people left the hospital and also how many pages they got at night as well as did they actually sign over their pager? Did they use night float? And what's interesting is that in our study despite providing them with this safe time to sign out a resident who was available to provide this night float and we're going to be in the call room to get some sleep and they knew that they could get more sleep if they did this interns signed out only 22% of the time. And we actually know from data that you know for each page that they got they were less likely to get sleep roughly 10 minutes. And so why did they not use it? So this was probably the most interesting thing to me and led to my work in handoffs because it was the fear of the handoff that led to them not to want to give away their professional ownership and how did they describe this? Well I keep my patients even though I could get more sleep if I signed out completely because I want to know what happens to my patients again the professional ownership issues. And then even more interesting was I worry that of course when it's not one of your own patients you tend to be less aggressive so highlighting that by signing out to a cross covering physician who doesn't feel that same professional ownership they're putting their patient at harm and so they're afraid to do to do these handoffs and that's why they're choosing to work even longer. And so what do we know? Well residents certainly have difficulty leaving the hospital they express wanting to care continuing care for patients but we also have systems that are set up that do not promote leaving and sometimes they're forced to lie about the hours that they worked to keep their residency program from not suffering. So my next question is well residents have to leave the hospital and sometimes we personally escort them out so what do they do when they're not at work? And this actually question is inspired by residents themselves. I was recently about a year ago I was talking to one of our current residents who was then an intern who said you know Dr. Roura we actually go home and continue to look online at the record and it's it's the thing we call epic stocking where we're just stocking the patient from home and sometimes we reach in and you know write orders and you know sometimes we call the cross cover and we may even call the patient in the room to confirm some interesting findings that we looked up and I thought oh my god this is kind of crazy because I thought I just did that but I'm the attending so that's okay. And so so you'll be surprised to know that the ACGME in 2011 and all of their standards regarding duty hours actually says that they require programs to ensure residents manage their time before, during and after clinical assignments. So this is a very lofty goal for programs you know we're going to be managing what people are doing out of the hospital and any tasks related to performance of duties even if performed at home count towards the 80 hours. Now I can tell you in sitting as a fly on the wall and some of the discussions at the program director's meeting there is a vehement pushback to this discussion and the other thing that I will say about this is that there is an ongoing companion discussion as to how we should be monitoring this because programs right now are universally not monitoring this. And so what our residents did on this was work led by Rod Deano and Allie Dekosky where they created a survey that they used at two hospitals here and at one of our affiliates to look at how often residents are doing this and in fact residents we just simply asked how often do you do this and think about it for your last inpatient rotation and it turns out that residents frequently are checking labs and especially on their post-call day they're often reviewing records and 37% are ordering inpatient labs from home on their post-call day as well as dictating discharge summaries and we're not alone in a UCSF study where they actually looked at the time of discharge summary dictations they determined that 50% of them are dictated when residents are out of the hospital and I should highlight that this is a this is actually something that has only become possible through the electronic health record this level of monitoring I do remember during my residency some people would call the lab and Genie's laughing because we have shared this story where some residents we know would from home call the lab to find out what the labs were but they would physically have to call different people to find out things or call the medical resident on call to ask them to look up things about their patient so this is now much easier so what about communication from home well and this picture is actually Michael Douglas I was recently watching Wall Street thinking how far we've come from cell phones and so so a significant time is spent communicating with the team I mean one of the largest things that residents do is communicate, corral people and so they're often emailing or texting their resident or cross cover emailing the attending and this was probably the most surprising to me was calling the ward patient so half of residents that they did this at least once a month from home and 20% said they did it on their post call day at least once during that rotation and so you can just imagine what kind of conversations lead to you calling and ringing the unit clerk to put you through to the patient but to highlight that basically a lot of communication is going on and another thing is paging the cross cover team two thirds of residents said that they did that at least once with 40% on their post call day so highlighting that they're not abandoning their post they are thinking about things and continuing to call back and perhaps advance care now what about that day off so the ACGME mandates one in seven have a day off one out of every seven days is a day off it's not average so it's an average it's not a mandatory it's averaged over the course of the month a resident must have four days off so when we ask residents do you come to work on your day off and this was actually have you done this once during the year 45% had reported at least coming in once during their day off and mostly it was for educational activities now this was before the 16 hour rule anecdotally I have seen interns who are off in the hospital coming to reports etc and that has placed program directors in a variety of in a sort of a controversial situation because you know somebody is off and they shouldn't be there but it doesn't feel right to be like please go home and don't receive education and so most program directors I know who I've talked to about this have sort of turned a blind eye or have said you're on your own and if you're here for your education that's fine and similar I didn't show this data but a lot of them doing research it's reassuring many of them are reading they're going home on their post call day to read about the cases and perhaps that's why they're spending time calling back and thinking about things so interestingly residents again do this more than interns residents work from home to prepare conference that makes sense but they're also more likely to call their cross cover team post call as well as email the attending so being a team leader they take greater responsibility or there may be something about the resident where they're the ones actively doing feeling more responsible and doing this so why do residents work from home and this was actually a follow-up study led by two of our residents Scott Siglin and David Cork and we expanded to one other institution in Chicago's this is three Chicago institutions similar findings from before 81% reported they work from home to monitor a patient's progress and then 65% to complete unfinished work and so that's concerning because that leads to the fact that the shift may not be designed correctly where they have to transfer a lot of work out of the hospital and I didn't show this data but less than 10% state it's because their program expects them to or that faculty expect them to so they're really doing this on their own it's something that they feel they should do as highlighted by the following 88% said the ability and skill to work from home is useful for future practice and actually in follow-up studies that one of our merits fellows and hospital scholars Shannon Martin is completing with interviews she's examining attending culture and practice regarding working from home and looking at the electronic health record and supervision so we may have more data on this in the future so do residents work from home clearly the answer is yes and why it's because they want to monitor patients progress and not because the program expects them to and they believe it's an important skill for future practice and I think all of the attendings in the room would not argue with that statement and so the question is what do we do about it so this is going to be a big issue for the ACGME to deal with do we start monitoring it there have been discussions about whether we should restrict privileges through the electronic health record for residents and so should we enable people to order labs from home the only problem with that comes up which I didn't show you is that the bulk of managing clinic continuity clinic one-third of residency in internal medicine is continuity clinic is all managed at home and mostly it's done when you're on inpatient on the post call day so you finish up post call you go home you know maybe rest figure out what's going on with your patients and then you catch up on your clinic patients before you go forward and so and then interestingly residents are more likely to exhibit these behaviors than interns so highlighting the similar theme that there's something about residency that actually gives them this inculcates this value okay so the next question is what do residents do when they should not work there are times when we all fall ill I noticed somebody was just sneezing and I know that some of you are sick and I was sick recently and I did come to work and so the question is what do residents do when they should not work now this was inspired by actually this photo here which is a picture of the H1N1 virus with its fuzzy coats and and I think some of you may remember that during that time we had a really difficult time managing the internal epidemic of H1N1 because there were residents who were coming to work sick and at times some of our hospital epidemiologists had to go up to certain patient care areas and physically remove people from their work post and say that you are sick and so this was not just here but it was elsewhere but this inspired one of our medical students who was in a MD-PhD program the mesh training program that David runs Bapu Jaina to actually investigate this issue further in residency and so this is called present eism and this is coming to work when you're sick so that's what I like about Peterson he doesn't let a little illness keep him off the job as you can see he's got his IV there so so what Bapu did was we partnered with the ACGME and they were already collecting data from 12 hospitals 537 residents and they had questions about whether these residents had come to work sick and actually interestingly the question was have you ever come to work sick at least once during the year and 60% of residents had reported coming to work sick at least once during the year now interestingly again residents were more likely than interns to work coming to work sick 62% versus 52% in this study and this was only PGY2 versus PGY1 so these weren't the most senior residents but something about being a resident made you more likely to come to work sick and when you examine literature in other industries about present eism especially nursing and other things it turns out like you know one question is why do residents espouse a higher professional obligation of patient care and one interesting thing that other studies have shown is that workers who believe their work and themselves are not easily replaced by others are more likely to come to work when they're sick and so this may be related to why the resident the team leader who feels like more obligation they not only have an obligation to the patients but they might feel that their judgment may be hard to substitute for and so this may also apply to attendees who you know rarely will take a day off of work from their sick when they're on inpatient service so in a follow-up study and this was actually done with Val Press who's here and others looking at Chicago hospitals and looking at a convenient sample of residents who attended the American College of Physicians meeting we simply didn't we had the ACGME data but the unanswered question was why we just knew that they did come to work sick but we didn't know why was it because they didn't have a jeopardy system in place was it because their program didn't have time off and it turns out that the reason was actually concerned for their colleagues they did not want to force their colleagues to cover so obviously feeling you know compassion towards their colleagues but that half the second reason felt responsibility to care for their patients so again this what and in the article that we describe the JAMA editors wanted us to write misplaced professionalism as the as the reason for this and so I highlight that just to say that you know there is not a controversy as to whether this is a good thing and then afraid other physicians would think they were weak this was only 15% so mostly it was regarding a worry about your colleagues as well as professional responsibility now in this study we also looked at what sort of adverse consequences might occur and this is very interesting roughly 10% of the residents in this sample thought they personally made a patient sick by coming to work sick but they were also stated that again it's not me 20% of other sick physicians translated their illness to physicians so highlighting that you know there clearly is this risk not only to patients but also to other colleagues and so in response to this question do residents come to work sick the answer is yes they do and this is even though they could harm patients and other personnel so this actually has a harmful effect not just for themselves but for others and why do they do it well it's because they have a high degree of professional responsibility and they don't want to burden their colleagues and once again residents are more likely to espouse these beliefs than interns and so now in thinking about where are we going to go from here so what you know what what can we do about this the first thing is just to summarize what do we know at this point so residents continue to espouse a professional work ethic consistent with nostalgic professionalism and that's what I hope everyone has taken away for this is they continue to care for patients after duty hours have ended they continue to not leave the hospital or lie about their work and also work from home and they also come into work when they're sick and this is in spite of current policies that are in direct opposition to these behaviors they continue to manifest these behaviors and you might wonder well why is that and so you know I know that many of you in the audience have spent a long time thinking about this and some of you with me and as somebody who works with residents in a formal role I can tell you that you can say all day and all night in orientation you know you must leave the hospital at this time but really the culture and the hidden curriculum is going to be what they learn on the floor from their other peers their other residents the way the faculty respond to them and the statement about strong work and so the hidden curriculum is the implied set of values residents observe in their day to day interactions which is far more powerful than the formal curriculum and so this is an issue that we need to think about so how can we you know correct this but before we correct it we I first want to highlight is this a problem because some of you may think great residents espouse nostalgic professionalism we're ready to go and and especially if you espouse nostalgic professionalism which I imagine many of you do and so one problem that I can think of is that when you have such a difference between expectation and policy it's very likely that it leads to confusion and moral distress about how to act professionally most of the literature about this is in nursing regarding end of life care so when nurses are forced to continue to provide aggressive treatments for patients when they personally don't believe that it's the right thing or they're concerned you know it leads to a lot of moral distress so similarly we're setting up our residents to have a a belief system where their beliefs are in contrast with what they're being told to do and more importantly what if we're promoting other unprofessional behaviors for example is lying okay and so probably not and if you're lying about your duty hours then are you more likely to lie about your procedures you know is it easy to just check boxes if you're just checking boxes about duty hours I don't think anyone's answered that question but I think one thing we need to think about is pause to say how are we setting this up the system up to reward people and what does it reward them to do and then most importantly we set up a situation of these unrealistic expectations of trainees if the nostalgic framework is used by faculty teachers to evaluate professionalism and so this leads to what I will call generation bashing and we've all seen this where people will say oh this new generation of physician is unprofessional and so can it really be the case that this medical students that we've selected and the residents that we are training in our current system are so unprofessional because of the system that has been forced upon them I think that that's a question that we need to answer and so one possible response to this is let's just abandon nostalgia you know leave it on to the wayside and go for lifestyle professionalism and actually I was amazed in this Haferty Castellani and Haferty article this is their conclusion of the article and this is what they state medical educators also need to realize that students and residents are likely to view physicians who practice a nostalgic professionalism as patronizing old fashioned outdated and unhealthy and so I know our medical students are smiling and so maybe we're just too outdated for everybody and so I was pretty surprised by this very controversial statement that was made by them and I'm not so sure we want to jump straight into lifestyle professionalism because don't we all have concerns about shift work mentality isn't that why we started this conversation so then I want to ask you I want you to think of a shift worker think of a classic shift worker in your mind you deal with them every day you know people in the police force nurses, pharmacists and are they all unprofessional because they are shift workers and so I think that's a question that we need to ask ourselves you know is by virtue of being a shift worker does that automatically make you unprofessional I mean everybody has to stop working at some point and be rested to go in the next day and the second thing to think about is even people in the military high degree of obligation they have enforced rules around how often they should work now I'm going to take nurses as a specific example and the reason I'm going to take nurses as a specific example is they have been doing shift work for a long time and I think we be hard pressed to say our nursing colleagues are unprofessional or exhibit shift work mentality and in fact what I'm going to argue is that they exhibit something else they exhibit shift work professionalism which we have not yet done in medicine because we don't know how and so one of the things that you'll see with nursing colleagues is you know nurses on the floor do not arrive late they arrive on time they are ready to receive a handoff at a specific time they have respect for people shifts so they arrive on time they use their time efficiently and they leave on time now of course there may be a specific case where a nurse has to stay and care for a patient but often times what you see is that they have a very rigid respect for the shift the other thing that they do is they don't have a nurse and so you can't interrupt a nurse during a handoff it's more than just a transfer of content it's also a transfer of professional responsibility don't try to interrupt a nurse during a handoff it won't work now the other thing is that they have espoused a team approach to patient care which has been a lot harder for us to do in medicine I don't know a nurse that when you go up to the floor and they say you know if they're on the floor they might say I'm just coming on shift I'm just learning about the patient but they are assuming care for the patient and so they have really espoused a team work approach where every patient they care for is their patient and they've changed the definition of professional ownership where it's not just a single nurse to a single patient but it's a unit and so when one nurse needs to leave the floor somebody else will cover etc and then lastly something that I think we all need to work on is collegial teams and so in addition to team into a teamwork approach to care should we be using a much more interdisciplinary team to care for patients that would provide a little bit of more the ability to actually adopt shift work in a more professional way now I want to just end with a few examples of where we have not adopted shift work but perhaps where we're not doing as well as we could because we haven't adopted shift work and so this is data that we actually collect around handoffs as part of an ARC study looking at interruptions and what's interesting is you know many people highlight pagers going off or you know cell phones, distractions people think that pagers and intercoms those are the most common types of distractions and in fact what we find in our studies around handoffs is actually the most common distractions come from people either side conversations that are occurring people venting about their job or you know or having a personal interaction because they're happy to see each other which speaks to the fact that we must provide a safe place for people to actually vent and to have these safe conversations but not at the time of the handoff but the second most common disruption was clinicians arriving for the handoff and so you might be wondering well how is that a disruption? Either they're arriving late and so that's one possibility or the shift is not structured in a setting where there's enough overlap time and so everyone is always perceived as late because the person who's arriving at 7 and they want to start the handoff at 7 they're never ready to go and so that's kind of the idea that I'm talking about with shift work professionalism that we've had difficulty in adopting now one of the things that we've argued for is and actually I've taught residents and students a lot about this in response to this whole idea of generation bashing and that there are generations not professional I say to them you know the handoff is your opportunity to be professional and so as opposed to saying that's not my patient you need to establish handoffs as a transfer of professional responsibility such that every patient is your patient and so that residents feel comfortable leaving the hospital and they're leaving the care of their patients in good hands and so that's something that we've started to teach now there's still a lot of areas to improve I would say one area that we have not really improved a lot is the idea of teamwork and collegiality and so in thinking about shift work in the way shifts should be structured and having collegiality one of the interesting studies that we've done and this work was done with Shalini Reddy and Holly Humphrey and Jeannie Farnan and a variety of others actually at Northwestern and North Shore we've looked at actually what behaviors are become more prevalent what behaviors become more prevalent during internship and a lot of people think internship you know everyone starts you know maybe disparaging patients or falsifying medical records or doing really egregious things and the answer to that is no very few people actually espoused those behaviors few people did them before few people did them after the bad news is the same people who did them before did them after and so there are few bad eggs that we need to be cautious of but the behaviors that actually went up in internship at these three hospitals that highlight what is the hidden curriculum we're blocking admissions disparaging the ER or primary care physician for missed findings that were later discovered and then misrepresenting an order test is urgent to get it expedited now I want to focus on disparaging the ER or primary care physician for missed findings later discovered because if the residents are you know our shift workers and adopting a team based approach this wouldn't be a behavior that we would be endorsing or espousing so that's certainly an area that we wanted to improve and with a grant from the ABIM Foundation we've actually developed a series of videos and we've conducted video workshops for hospitalists at all three institutions as well as residents and this is actually a sample vignette called scoring on call which is all about trying to block an admission but the poor resident here wastes more time blocking the admission than if they had accepted it and actually taken care of the patient and so and then working through a debriefing exercise so I don't have all the answers but I just wanted to give you a foray into what some of the current thoughts that I had regarding duty hours and professionalism were and I think we have some unanswered questions that we could answer in this room and think about how to reconcile these problems and the first is how can we reconcile our definition of professionalism with this new world of resident duty hours and I've attended a lot of the McLean ethics seminars where we've talked a lot about professionalism but sometimes as we talked about in that study for those Hopkins residents it's too hard for them to put that into practice the way the system has been set up and can those who are nostalgic embrace shift work professionalism I don't know you know so that's a question that we need to answer and the way our system is set up what tools are needed to promote evaluation of professionalism in this new world will it be that any resident who leaves their patient is automatically going to be assumed as unprofessional what will we do about that and then lastly probably the most important is what is going to be lost so I think one of the most interesting findings is you know in the New York in the Northeast region they're less concerned about resident ownership and so clearly we will evolve and people will come to accept new systems but we need to pause and think we will be lost and left off the table in order to think about that and the last thing I wanted to throw out here before ending is that there's clearly something about being in residency that still espouses a very strong work ethic and nostalgic professionalism because as you've seen in all of the studies I've showed you the residents are more likely to display these behaviors than interns and I have a hard time believing that we admitted an entirely different class of people across these three studies in our nation so there's something about the training itself in which they learn this and so we want to continue for them to learn that but how can we have them learn it in a safe way where they're not exhibiting behaviors that are contradictory to the rules so with that I'm going to pause and thank many people who are listed on the slide and there are too many to name so many of you know who you are so thank you for comments and questions yeah so I'm a shift worker unfortunately in the emergency department so I thought that your last comments about shift work professionals are quite up to pro and I would suggest that looking at it in the laboratory in the emergency department would be interesting we face these challenges every day with residents who are whether explicitly or implicitly forced to stay an hour or two after their shift because no one will take their procedure that they're trying to sign out I think that's an interesting place to look and I think we haven't developed a culture where we accept I came from a training program in New York and we would say the bell was ringing literally the bell was ringing you're a ghost go and when I moved to Michigan I came here that's not the same mentality that that occurs here in our emergency department aside from that though I actually wanted to kind of one of the outcomes you're looking at is ownership idea and I want to take a step back and ask you to reflect on the fact that potentially all of us attendings education or our residents is that they have to know everything about their patient and we picked them about their patient but what about our ownership the essential issue of education is what residency is for versus clinical servitude always comes up and we don't actually address the head on who's responsible if my medical student needs to go for something or a resident needs to go for something is it my patient or you're supposed to know the patient and I wanted you to address that because I think do we think as that we actually don't have ownership patients and we're less professional I don't think anybody would say that but when the resident does that we wouldn't say the same thing those are great points and I definitely want to highlight that in New York there's also an independent body that's paid to actually go and secretly surprise residents and program directors and so I understand from my visits to New York that the threat of that is very powerful and so while we have implemented duty hours in the rest of the nation we have not implemented the monitoring that New York has which many people have described as a problem because we have not gotten to where New York has been and then also regarding being an emergency room physician I think that was a great segue and I missed my chance to discuss the emergency room and labor and delivery but those are both examples of shift work and I think we're not going to dismiss our colleagues as unprofessional there as those professions they have handoffs and shift beginning and end rituals that are way more extensive than anything that you have in medicine where all hands are on deck and people are having dialogues and things like that so we have a lot to learn from our colleagues in those fields and then the last question about faculty involvement and ownership of patients is fascinating and I think we will probably have more data on that and hopefully discussion when Shannon completes her study of what faculty believe their level of supervision is and also what they are learning from the electronic medical record because we have seen anecdotally the electronic medical record has really changed some of the dialogue and the perceptions that the residents have of what the faculty know it's not uncommon for them to be like oh you already saw that and I'm like no I want to hear from you you tell me what you saw so I understand that you know what you saw and that we can have a dialogue and I think we are seeing obviously with the supervision accreditation rules which I did not discuss that also came up in line with the duty hour rules in 2011 we are seeing greater involvement at the front line and I know that Jeanne and I have been involved in several programs advising them who are starting nocturnist programs where the hospitalist is actually not just there at night doing uncovered but they are actually dedicated and their goal is to actually teach at night and help the residents through with their admissions and provide some of that level of ownership and so I think the comments you raise are really important comments and how long from a patient safety perspective can we get away with being like oh I was just the attending ask the resident I don't think that those days are already over and so we are going to be forced to really take a larger ownership of our patients. What do you do in the time that you are away from the hospital and it's not just work that you are doing, it's not work work but you are also part of a family you may be a parent and anybody with kids knows that that first year you don't sleep a lot so are we supposed to is the ACGME going to recommend to the residents when they have children because it just can't regulate the number of hours. Well I should say I don't believe the ACGME would do that but I can't speak for them but I will say that I did not mention the following which is that in the rules it says and again I don't know how these rules are operationalized but these are the rules by which site visits are going to occur and citations are going to be given that faculty at that institution must be role modeling and we at work life balance and so I think I for one would fail at that rule so I think that we're probably going to need to have a more open dialogue about this and let our residents be more effective and healthy role models and I do believe there has been discussion around attending duty hours and so we should bring that up and the discussion is occurring so will people lie, same sort of issues but it may not be long until people are thinking more, we're thinking more like Europe. Terrific talk and I also really appreciate this notion of shift work professionalism and how it relates to team based care and so on but I wanted to ask you a kind of researchy question I reviewed a paper a few months ago where it was a qualitative study just talking to residents about why they stayed late and one of the issues that came up I really hadn't thought about before but it was this sort of tension in professional values with dedication to the patient being sort of exemplified by staying late but also exemplified by staying late was being inefficient oh yeah and I hadn't sort of thought that through before but it was interesting to me that people didn't necessarily see staying late as always being you know that was a display of your dedication to seeing things through sometimes people and this was reflecting on their colleagues so the resident would say well yeah I have some colleagues who occasionally stay late because they really need to I have others who stay late all the time because they're really inefficient yeah no that's a great point and I think anyone who's been involved with program administration or worked with a resident in this category has understood the issues of a resident who's not efficient and one of the challenges that I think we face is in our current duty hour structure we don't have a safe place to train somebody who's not efficient they're really expected to be on the ground efficient from day one and so and most programs do not have adjustable caps or things like that where there's a safer period to allow for reflection and learning because most people's efficiency actually improves during the year and so it's interesting in that study the efficiency issues were highlighted and I can imagine it's partly driven by the fact that many chief residents now around the country say they've been forced to turn into police as opposed to being teachers and so they often are on the wards you know trying to get the residents to leave the hospital and so if you're always that resident who's labeled by chief resident or program director is staying late you're gonna be you're gonna feel like okay they're not you're getting that mixed message maybe your faculty's like oh great job staying but your program leadership is not happy with you and so I think that's what we're seeing is greater push to be more strict about these rules is what's playing out with the residents I just wanted to piggyback a little bit on what Matt had said about the sort of inefficiencies and how this is really sort of an area where GME is really affecting you right so it's I've heard you make the analogy that I love of the residency training is like the sandwich right and so when you smash a sandwich together the stuff that squeezes out the sides is usually all of the fun of residency but also all the education and I know we've got a bunch of fourth years who are submitting their rank list this evening and are we not doing enough to prepare them for internship and in fact could we be arming them with these skills so that they are out of the box ready to be interns yeah now that's a great question and in fact a major hot topic on list hosts everywhere and one of the in surveys of program directors they've actually surveyed program directors to say what do you expect your interns to be able to do from day one and the top thing is to execute a handoff to provide a sign out execute a handoff discharge it's not procedures it's not this other stuff it's around communication and mechanics of doing an admission history and physical and so that brings up an interesting question because as a fourth year student you know there could be a huge time that elapses between your last clinical rotation and then the point that you arrive to your internship and so many programs many medical schools are now describing more fourth year curricula similar to our own to a boot camp to get the intern to get people ready for internship the challenge for that is there's an interesting dialogue and I think Shalini knows more about this than I do about whether the fourth year is actually should be getting rid of completely and so and so there are people in the room that are like don't get rid of the fourth year we need it and then there are other people that are like oh the people are just taking electives it's not a big deal and I can tell you as someone who's served as a career advisor I think that would be a really bad idea to get rid of the fourth year since people still need time for career decision reflection as well as advanced training we describe and so the perception is that fourth year is just an unclaimed area so I think there's a lot of opportunity there well so many of the studies in medicine tend to show a decline or deterioration in empathy compassion let's say professional attitudes as medical education and training continue the data you showed us on the difference between the interns the first year residents and the second year residents is quite the opposite and I find it very reassuring data to think that here at last we see this commitment to I don't know what's the nostalgic professionalism commitment to the patient increasing as training goes forward I would love to see that carried forward perhaps into fellowship training and practice to see if that's a remarkable trend and quite different from a lot of the earliest studies yeah no that's a great question and something we'll have to monitor I think with our first test case with our new interns working 16 hours how will they change when they work a longer shift next year well I want to thank you for everybody it was a wonderful presentation thank you