Models of Residency Rotations

Possibilities to help programs meet the 80-hour rule and enhance education

Richard H. Bell. Jr. MD, FACS

In the fall of 2002, the Department of Surgery at Northwestern University hosted a national "think tank" on resident work hours.1 Our primary goal was to try to develop some practical schemes of resident rotations that program directors could adopt to their local environment to meet the 80-hour work week while at the same time maintaining or hopefully enhancing resident education. Four models which emerged from the think tank and are described below. They are presented in increasing order of radicalness, that is, in the degree to which they differ from current practice. Current practice is assumed to be hospital-based teams of residents who work with multiple attendings on a service and who take night call on a regular schedule, typically every third night.

The four residency training program models were called:

1. the Stretch Model
2. the Night Float Model
3. the Apprentice Model
4. the Mastery or Case-Based Model.

Following is a definition of each model with a description of its key components, strengths, and weaknesses.

The first model, the Stretch Model, is the most traditional model, which we nicknamed "q4 and out the door." In this model, residents take call every fourth night (or less frequently) and leave early the next morning after call (although up to six hours are allowed for transition of care). Both reducing the frequency of in-house call and sending residents home after 24 hours of duty help to reduce the number of work hours in the week. The exact frequency of call in any given program would depend on the number of residents available. A typical resident week in the stretch model is shown below:

	MO	TU	WE	TH	FR	SA	SU
Day	12	12	OFF	12	12	12	OFF
Night	OFF	12	OFF	OFF	OFF	12	OFF

STRETCH MODEL: HOURS PER WEEK AVERAGED OVER 30 DAYS EQUAL ABOUT 86

The figure above assumes a 12-hour day time rotation. Using every fourth night call, the hours exceed 80. If residents ever had to stay in the morning after a night call to transfer care, this would of course add to the number of hours. Using an every fifth night call schedule can get the hours per week to below 80 hours, but may not be practical for most programs. The other options are to reduce the length of the workday slightly or maybe just reduce the length of the workday on weekends. Another possibility is to apply for a 10% exemption from the RRC, which if approved would allow an 88-hour week.

The stretch model is probably the easiest way, administratively, to get to an 80-hour week, but it has no real educational advantages other than shortening the work week and presumably giving residents more time to read. The advantages of this model are that it is the easiest to implement and has the least amount of impact on faculty. It preserves the resident team concept, a culture which residents seem to embrace. The biggest disadvantage to the model is increased cross-coverage at night, potentially "stretching" the residents beyond reasonable patient loads and creating a lot of situations where patients are being seen at night by residents relatively unfamiliar with their history. This model can impact operative experience negatively, because one-fourth or one-fifth of residents must go home during the day, when most operative cases are done. It could eliminate some or all specialty experiences or require non-teaching services, because the pool of residents available during the day is reduced.

The Night Float Model consists of a traditional resident team system, except that a percentage of the program's total residents are designated to work a permanent night shift, usually for a month at a time. In most programs, residents will wind up on night float for about two to three months per year. Residents assigned to nights leave in the early morning after handing over patients to the day team. Several teams would work the day shift, that includes a one hour overlap with the night team allowing for a robust "sign-out." Teams working during the day would leave in the evening and take no in-house night call. There is again an overlap hour in the evening for "sign-out." The "night float" team would work a night shift six days per week, although larger programs may be able to have a five night per week night float. The day shift teams would include a mixture of junior, senior, and chief residents, and a combination of these from various day shift teams would share weekend call and cover the night or two not covered by the float pool. Night float members would not be allowed to schedule vacations during the one- month periods of night-float duty. A typical resident week in the stretch model is shown below:

	MO	TU	WE	TH	FR	SA	SU
Day	OFF	OFF	OFF	OFF	OFF	OFF	OFF
Night	13	13	13	13	13	OFF	13

NIGHT FLOAT MODEL: HOURS PER WEEK AVERAGED OVER 30 DAYS EQUAL 78

If two hours of core educational conferences are held early in the morning or late in the afternoon, night float teams can conveniently attend without exceeding the hour limits.

The strengths of this model are that it is not particularly disruptive compared to the current system, that workloads are shared and that the resident team concept is maintained. Residents would still assume their teaching roles, and clear lines of responsibility are easily drawn. Since the same team is in the hospital most nights, the senior resident can easily assume a teaching role. But this model may not work for smaller residency programs, and it could potentially dilute the operating room experiences because it again reduces the amount of time residents work during daytime hours when most operating procedures are performed. It may require instituting non-teaching services, since the effective resident day pool is reduced, and could require eliminating some or all elective rotation experiences to free up persons to cover the float pool. Other surgery programs have described their programs' approaches to using a night float team.2,3

The Apprentice Model is defined as one resident working exclusively with one or two faculty members over a sustained period (one-three months). In this model, residents work side-by-side with their assigned mentors in the operating room and outpatient office. Residents take home call when their mentor is on call and may need to return to the hospital when their mentors are called for a consult or emergency. Residents are involved only in the care of their mentors' patients. Faculty members would need to be selected carefully based on dedication to education and an appropriate practice profile. If junior residents participate in an apprentice model, early intensive technical skill training would be required, preferably in a skills laboratory environment, so they are equipped to work effectively with their mentors in the operating room. It would be a clear expectation that mentors allow residents to perform cases suitable to their level of training with the mentor assisting. The apprentice model lends itself particularly well to certain subspecialty areas like colorectal surgery or breast surgery but can be used for general surgery rotations as well. Because apprentices take no regular in house night call, it is usually possible to construct a work week that is less than 80 hours long, even if the resident has to come in at night once or twice a week. A typical resident week in the apprenticeship model will be more variable than in the first two more traditional models. An example of a typical week might look like the one below:

	MO	TU	WE	TH	FR	SA	SU
Day	12	14	8	14	8	4	OFF
Night			3		2		OFF

APPRENTICE MODEL: HOURS PER WEEK AVERAGED OVER 30 DAYS EQUAL ABOUT 60-70

In the figure shown above, the length of the day varies because OR days may be longer than outpatient clinic day(s). In the example above, the resident has to return in the evening on two occasions for problems and comes in on Saturday for rounds. The resident must be guaranteed 24 hours free of any clinical responsibility (including carrying a pager), so Sunday is shown as a day off. Ideally, the attending physician would cover on the resident's day off, but other arrangements would be possible.

The Apprentice Model requires some investment of resources to provide assistance to staff physicians who are not assigned a resident (with a smaller faculty:resident ratio, not all faculty will be able to have a resident work with them). This model also requires some in-house presence of other health professionals to watch patients on the ward when the apprentice is in the OR or clinic with the attending. This model's advantages are that it provides continuity of care for patients and allows the resident to participate in care across the continuum from preoperative evaluation through surgery to postoperative follow-up. This model has the strong advantage of mimicking the real life of a surgeon. It promotes a depth of interaction between the resident and their mentors as well as with the patients. Learning can be tailored to the resident's learning needs, and careful evaluation and feedback can be given, since the extent and scope of direct observations would be maximized. It reduces the need for cross coverage, and potentially provides residents with early experiences in the operating room. One strong advantage of this model is that it gives program directors the opportunity to assign residents according to the quality of the teaching experience.

The disadvantages are that not all faculty members would be assigned a resident, leading to possible divisiveness. Faculty with limited clinical practices who are good teachers might not be afforded teaching opportunities because of their practice profile. There would be scheduling challenges that would need to be overcome. The system would need to be flexible, in case there were serious personality clashes or other problems between a mentor and his/her mentee, so reassignments could be accomplished. This model is somewhat resource intensive in that physician assistants or other health professionals would need to be available to assist those faculty members without mentees. And lastly, a sense of resident team would be lost with this model.

The Mastery (Case-Based) Model was defined as a system in which patient cases are assigned to residents based on the residents' learning needs irrespective of attending or team assignments. Proficiency, knowledge and skills associated with diseases and operations are measured by personal progress, not by time. Proficiency is verified through formal assessment, and then residents are allowed to move on to other areas, and just as importantly, not required to scrub on operations they have mastered unless they feel the need to refresh their knowledge. An adviser would need to be paired with each resident to oversee the resident's progress using performance portfolios. In such a system, participating residents would meet each week to receive their final patient/attending assignments for the coming week based on preoperative, intraoperative, and postoperative experience needs. Residents would be responsible for making arrangements to review the cases with the appropriate attending. Residents would round on their own patients in the morning and go to the clinic or operating room depending on their assignments for that week. They would not necessarily take regular night call, but could take call from home. Either in-house or home call can work with the model. Residents would follow all of their assigned/operated patients, irrespective of attending or service. There would be an outpatient clinic block, which would probably have to be attending-based, since it would be difficult for residents to follow-up on their patients in multiple ambulatory offices. It would be critical that learning expectations are made clear at the start and are mastery-based, but broken down by years for planning purposes. An example of a typical week might look like the one below:

	MO	TU	WE	TH	FR	SA	SU
Day	12	14	10	14	8	4	OFF
Night		3			2		OFF

COMPETENCY MODEL: HOURS PER WEEK AVERAGED OVER 30 DAYS EQUAL ABOUT 60-70

In the model shown above, the length of the day varies because OR days may be longer than outpatient clinic day(s) and, some days, the OR cases may be longer than on other days. In the example above, the resident has to return in the evening on two occasions for problems and comes in on Saturday for rounds. The resident must be guaranteed 24 hours free of any clinical responsibility (including carrying a pager), so Sunday is shown as a day off and some other physician would have to cover on the resident's day off.

The advantage of this model is that it reflects principles of adult learning in that residents assume more responsibility for their own learning and development. It is based on attainment of competence rather than an accumulation of weeks, months, or years. It decreases time spent in noneducational activities such as participating in too many of any one operation. Once basic competencies are met, the clinical experiences can potentially be tailored to individual residents' needs and interests. If such a system were widely adopted, aggregate performance data could inform the RRC on the number of cases needed by residents to achieve proficiency. On the other hand, several disadvantages to this model must be kept in mind. This model would significantly complicate communications between attendings and residents and would require sophisticated scheduling methods. The entire surgical care system would need to be less dependent on resident services than is currently the case, and faculty would undoubtedly have to assume more responsibilities for their patients' care. It would also require a more robust performance evaluation system than what currently exists.

Although the extent of resources required for implementation varies from model to model, additional resources will definitely be needed for all of the models. Unless additional residents are added to surgical programs, other employees will be required to do the work that will no longer be done by residents because of the 80 duty hour maximums. Nurse autonomy, perhaps increased nurse staffing, and clinical pathways and protocols for common problems will need to be accentuated. Enhanced information technology and communication systems are needed to make resident work more efficient and patient information exchanges more consistent. Faculty will need to hone their skills as teachers, evaluators, and providers of performance feedback. Refined standards and measures for evaluating proficiency will become more important. Early intensive technical skills training will aid in helping residents function and learn more efficiently in the operating room. This will be important, because the operative experience for residents will have to be spread more evenly over the residency than currently happens in many programs. Additional or alternative educational delivery systems to replace traditional conferences are needed so residents can study and learn in the evenings, and commit their time during the day to learning from direct patient care activities.

Mixing the models

It is quite possible to mix the models in constructing an overall residency program. At Northwestern, we have added a night float pool. We retained some traditional inpatient teams during the day but changed several daytime rotations to the apprenticeship model. In my next installment for this Web site, I will describe in some detail how we have constructed our program and how the models can be mixed to achieve educational as well as work hour goals.