Resident Time Spent in Clinical and Educational Activities at Home: Implications for Duty Hours FREE

The Accreditation Council of Graduate Medical Education (ACGME) recently finalized duty hour restrictions to be implemented by July 2011.¹ The new standards require programs to ensure that residents are managing their “time before, during and after clinical assignments.” With increasing use of electronic health records (EHRs), residents could continue to participate in clinical activities after leaving the hospital. Although these hours are considered subject to the ACGME duty hour limits, no study to our knowledge has examined the extent of this practice.² Our study aims to quantify the extent and type of out-of-hospital work reported by internal medicine residents at 2 Midwestern teaching hospitals with EHRs.

An anonymous 1-page survey was created to assess clinical activities that could be performed from home via telephone, Internet, or remote access of EHRs. These activities included checking laboratory results, reviewing records, placing orders, communicating with ward teams, managing clinic patients, and conducting activities such as independent didactics and research. Residents were asked to rate the frequency of these activities during their last inpatient service month. Residents were also asked if they ever performed these activities on days off or on post-call days.

Paper surveys were distributed to internal medicine residents at mandatory house staff meetings at 2 Midwestern teaching hospitals in June 2010. The surveys were entered into an Excel database and analyzed using STATA 10.0 (StataCorp, College Station, Texas). Site-adjusted analysis of variance and logistic regression were used to assess differences by site or residency training year. This study was exempt from institutional review board review.

Seventy-three surveys (65%) were completed (51% by interns). Response rates by site were similar (61% vs 69%; P = .35). Many residents (93%) reported checking laboratory results from home at least once, with 45% doing so frequently and two-thirds doing so on a post-call day. Nearly 70% of residents reported ordering inpatient laboratory studies from home, with 37% doing so on a post-call day. Two-thirds of residents (66%) reported paging their cross-covering teams at least once in the last month, while only 5% did so frequently; 39% of this communication occurred on the post-call day. Interestingly, almost half (45%) of residents reported calling their ward patients from home at least once in the past month, and 21% did so on the post-call day. Clinic management was often done from home: 78% of residents reported calling clinic patients from home, 85% reported checking laboratory results from home at least once in the past month, and 33% did so frequently (Table).

Nearly all (99%) residents reported researching patients' illnesses from home, and just under half did so on a post-call day. Likewise, 83% of residents reported doing research from home, with one-third doing so frequently. Regarding days off, 45% of residents reported coming to the hospital at least once on their designated day off to conduct clinical activities, and two-thirds reported doing so for educational activities. When compared with interns, residents reported more out-of-hospital time preparing for conference (residents, 56%, vs interns, 21%; P = .003), e-mailing attending physicians (residents, 28%, vs interns, 6%; P = .02), and contacting cross-covering teams on the post-call day (residents, 56%, vs intern, 30%; P = .04). Site differences were observed for clinic management and conference preparation.

As residents' work hours are restricted, it is important to understand out-of-hospital work. Electronic health records have allowed many residents to complete clinical tasks from home, which are not routinely counted as part of duty hour reports. Moreover, this work is sometimes taking place when residents are most fatigued after extended shifts or on designated days off. Given concerns about shift work mentality with duty hours, these behaviors suggest that residents are continuing to advance care for patients even after ending their shift. Further study is needed to describe the extent of this practice and whether it poses a safety risk.

Correspondence: Dr Arora, Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 S Maryland Ave, MC 2007, AMB W216, Chicago, IL 60637 (varora@medicine.bsd.uchicago.edu).

Author Contributions: Dr Arora had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Deaño, DeKosky, and Arora. Acquisition of data: Deaño, DeKosky, Appannagari, Doll, Georgitis, Potts, and Arora. Analysis and interpretation of data: Deaño, DeKosky, and Arora. Drafting of the manuscript: Deaño, DeKosky, and Arora. Critical revision of the manuscript for important intellectual content: Deaño, DeKosky, Appannagari, Doll, Georgitis, Potts, and Arora. Statistical analysis: Deaño, DeKosky, and Arora. Administrative, technical, and material support: Deaño, DeKosky, Appannagari, Doll, Georgitis, Potts, and Arora. Study supervision: Arora.

Financial Disclosure: Dr Arora reports receiving funding from the Accreditation Council of Graduate Medical Education.

Funding/Support: This study was funded by the University of Chicago.

Role of the Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Additional Contributions: James Woodruff, MD, Internal Medicine Program Director & Chief Residents at the University of Chicago provided administrative support; Vivian Tsang, MD, Mercy Hospital, and Meryl Prochaska, BA, University of Chicago, provided research assistance. We thank the participating residents at the University of Chicago and Mercy Hospital.