They also continue to do more traditional service activities at the Veterans Affairs medical center, including drawing blood, performing electrocardiograms, and transporting patients. Weigelt These programs are very well attended because program directors are worried. 2004;139(5):490–494.  W. Wartman The researchers did not find any major differences in patient outcomes between internists in their first year of practice who were exposed to reforms and those trained before reforms came into effect.  CJWasserman The similarity between sites and years suggests that the trainees were consistent in their use of the survey tool. These hours were not included in any category. Curet Not Available, ACGME outcome project. Residents spend a large amount of time in noneducational activities. Examples of the 5 categories were discussed and clarified. The discussions that follow this article are based on the originally submitted manuscript and not the revised manuscript. There is no difference in attendance requirement by resident postgraduate level. The mean number of hours worked was 77. The law was named after Libby Zion, who died in 1984 at the age of 18 under the care of what her father believed to be overworked resident physicians and intern physicians. Resident Work Hours and Conditions of Post-Graduate Trainees. is a term that refers to the often lengthy shifts worked by medical interns and residents during their medical residency. The SAS statistical package used was version 8. Such a shift will force many changes within our academic medical centers. All Rights Reserved. | September 11, 2019.  KSPeoples How do you put the fun back in the equation? Graduate medical education is now funded by Medicare, Medicaid, hospitals, medical schools, voluntary health organizations, and faculty practice plans. Whether they have reduced the residents' noneducational time is unknown, although a reduction in hours and change in tasks for residents after the addition of health care technicians and physician assistants have been recently reported.17,18 Hospital support has come in the form of a blood-drawing team and an intravenous line team. Vijay K. Mittal, MD, Southfield, Mich: I just wondered about changes in the curriculum. The same reform forbade individual shift lengths from exceeding 30 hours. Before 2003, physicians in training in US internal medicine residency programs routinely worked more than 80 hours a week, with shifts often lasting 30 hours or more Concerns about high work hours for resident physicians first arose in New York state in 1984 after a widely publicized death in a teaching hospital. The study examined whether 30-day mortality, 30-day readmissions and inpatient spending varied depending on whether physicians were exposed to resident work-hour reforms. Long hours are a component of medical residency and preparation for an occupation that requires hard work and dedication. Their origins, along with the term 'duty hours,' are found in traditional models of residency as brief periods of intense training, during which responsibility for patients rested with residents 24 hours a day, 7 days a week. I would direct you to a paper Dr Myriam Curet presented looking at reducing unnecessary floor calls to the residents. We attempted to better quantitate resident work within our system of care. The amount of time spent in noneducational activities was lowest at community hospitals (17%) and similar at the Veterans Affairs (23%) and academic (22%) medical centers. Dr Brasel: Our chiefs are as in compliance or as out of compliance as the rest of the service or the rest of the residency.  WBWallace This has been a topic of debate since 2003, when the Accreditation Council for Graduate Medical Education limited resident work hours in the United States to a maximum of 80 hours weekly.  RLSmith The surgical residency program at the Medical College of Wisconsin graduates 6 categorical residents per year who rotate at 3 core Milwaukee hospitals (Froedtert Memorial Lutheran Hospital, Clement J. Zablocki VA Medical Center, and Children's Hospital of Wisconsin) and 2 affiliated community hospitals. For this reason, 250 hours were not accounted for. Jena is the lead author of a recent study published in The BMJ evaluating the impact of resident work hours on long-term quality of care. It is a brave new world. With the increased patient load and fewer residents in the hospital at any one time, our residents do not sleep much on call. That is, were the interns doing more scut work at the beginning of the academic year than they were further on, because that would lend some more validity to your model? You talked about what Dr Myriam Curet has done. As a whole, the program was compliant with the 80-hour workweek, averaging 76.6 h/wk (Table 1). You imply in the manuscript that the similarity and categorizations of their time spent among PGYs and sites suggest more responses wouldn't change the results, but we need more verification that the nonresponders were the same as the responders. I think minimizing much of the paperwork, administration, and the information overload and really getting back to both more of the focus on actual education rather than the administration of much of the training program and focusing on taking care of patients will help, but I certainly don't have the answer to that question. “When they have to excuse themselves from the [operating room] in the middle of a case, they feel like they didn’t get what they needed to get out of it.”. There have been a few studies that have looked at the health assistant/health technologist as somebody to work with that information transfer.  SE Reducing the non-educational and nonclinical workload of the surgical resident: defining the role of the health technician. What’s more, 51.9% of residents reported experiencing symptoms of burnout. Educational experiences need to be planned and scheduled; we have a responsibility to teach our trainees rather than just letting them experience patient care and hoping they end up as competent surgeons at the end of their training. Fewer than one quarter (21.9%) of work hours were unrelated to educational activities. Since 2017, when the latest reform was implemented by the Accreditation Council for Graduate Medical Education, the cap remains 80 clinical … Thomas R. Russell, Chicago, Ill: One thing that I hear frequently from program directors is the idea of continuity of care, and you are obviously shifting some of your care to nonphysicians, physician's assistants, nurse practitioners, and subinterns. At any given time, 42 general surgery residents are assigned to clinical rotations at 1 of these 5 hospitals. Eliminating these activities would bring our rotations into compliance with the 80-hour workweek. For more health care news — plus research, analysis, commentary and more — please visit: Designed by Elegant Themes | Powered by WordPress, How work hours affect medical resident performance and wellness. Public Citizen petitions the Occupational Safety and Health Administration (OSHA) to implement regulations for the work hours of resident physicians and subspecialty resident physicians, (i.e., medical and surgical fellows), building from the recommendations made by the Institute of Medicine in its 2009 Report, Resident Duty Hours: Enhancing Sleep, Supervision, and Safety.  MMWelch We attempted to better quantitate resident work within our system of care. Data about what the residents are doing on duty, rather than simply how many hours they spend on duty, are required.  TR Improving resident work environment: evaluation of a novel cooperative program. Whitcomb Scher What effect do you think the change is going to have on the surgeon practicing 20 years from now? Other than a time and motion study that would be very difficult and also very expensive to complete, this at least allowed us to get an initial handle on this situation; they do spend an inordinate amount of time doing things that in an immersion may have been educational once, but I think we have to get away from that philosophy. Does healthcare “hot-spotting” really save money and…, How many Canadian kids suffer harm linked to vaping…, New hormone therapy study restokes debate over breast cancer risk, Canada’s health care crisis is a ballot box issue says CMA. Accessibility Statement, Hours Spent in Each Activity by Resident Level. On average, I worked 11.1 hours each day: 8.46 hours per day if I was on scheduled shift work such as in the emergency department or urgent care and 12.93 hours per day if I was on Inpatient Wards.Since I spent 9 out of 12 months of the year doing inpatient rotations, this translated to approximately 60 to 80 hours per 6-day workweek for most of the year. The study examined whether 30-day mortality, 30-day readmissions and inpatient spending varied depending on whether physicians were exposed to resident work-hour reforms. The following section will review the outcome of the EWTD for medical residents since its implementation. This approach will require more curriculum and faculty development for all of us and will need to be focused on the Accreditation Council for Graduate Medical Education competencies.9 The model may need to incorporate aspects of graduate school curricula, rather than the experiential or immersion model that has functioned as the foundation of surgical residency for so long.5,7,8 Carefully planned conferences, study hall, skills laboratory training, and guided self-study are ideas that need to be explored and adopted more widely.7,8,10-12 Even the operating room, an obvious educational venue, is underused.13.  JJ Honoring the "E" in GME.  R Financing graduate medical education and limiting resident work hours: a political assessment. Residents spend a large amount of time in noneducational activities. Long and unpredictable work hours have been a staple of medical training for centuries. Some residents may work 45 hours a week, while others work much more. Still, he wasn’t surprised to see little variation in performance between the two groups. Why hire an expensive PA when you can hire an entry-level secretary for those things? That time might indicate some of the accuracy of the survey. Our data have weaknesses: a 52% response rate and the bias of self-reporting.  JA Medical education crisis: not just an issue of work hours [commentary]. So a group of researchers decided to follow thousands of medical residents at dozens of hospitals around the country. We have to change our model. “It’s not as if fatigue is this thing that you can avoid and never be exposed to,” said Imrie. Focusing on excessive hours deals only with the symptoms, not the root cause of the problem.22 It is unfortunate that much of the work-hour discussion focuses on resident health and satisfaction, patient outcomes, and costs.23 What is missing is the Accreditation Council for Graduate Medical Education emphasis on competency and outcome; the discussion should be centered on how to educate competent surgeons and how best to use the time from an educational perspective. For Ahmed, it is not counterintuitive that shorter hours can lead to unhappiness among some trainees.  MMAshley This study — a… It would also generate a large amount of time for educational activities within our training program. The answer: not much. And secondly, can you tell us about that resident who had the 22-hour average workweek? Even our nurse practitioners and our nurse clinicians who help with a lot of that paper tracking have complained that they are overqualified for much of the information transfer that is being shifted now more towards the nurse practitioners and nurse clinicians. Duncan multiple comparisons method was used for pairwise comparisons.6 The mean percentage of noneducational time between weeks with more than 80 hours worked and weeks with 80 hours or less worked was compared using t test.  KGTenenbaum One study showed that medical interns made 35.9 percent more serious medical errors during a schedule with shifts of 24 or more consecutive hours than on a reduced schedule with shifts of 16 hours or less. Haluck I have worked in many hospitals, and we have had IV teams and blood-drawing teams even at the VA for a long, long time, so it would be really nice to know the specific activities.  DJCochrane Although some might argue that some service activities provide educational opportunities, the education is usually subordinate to service. At that time, the overall workweek averaged 90 hours. Five categories were defined: patient care related to educational objectives, required educational activities, patient care unrelated to educational objectives (scut work or noneducational patient care), off-duty educational activity, and off-duty hours.  JKutner “It’s something that touches all of us, and we need to figure out how to manage and mitigate it.”. If education is our goal, different strategies may be necessary. I do not know whether our residents completed the surveys at the end of the day or at the end of the week, but they were required to turn them in at the end of the week. They are not only worried because of the restrictions of these new rules, but they are worried because of reports of summary withdrawal without probation and the probation of some programs at prestigious institutions. In July 2003, the … Sometimes, up to 6 forms, including discharge summaries that are 5 pages long, consume many hours. 15 Each makes the case that the others should fund the current workforce shortage occurring as a result of decreased resident work hours, and programs must try creative solutions to get by. Total work hours and noneducational work hours were analyzed by resident level, rotation, and category. Brasel KJ, Pierre AL, Weigelt JA. Maximum shift length of 13 hours. A better understanding of how residents are using those 17 hours would help us all. The decades-long debate over resident duty hours shows no signs of slowing. The survey response rate was 52%, covering 110 workweeks. In 2016, the ACGME requested position statements on resident and fellow work hours from every specialty society and program directors association. According to the organization’s 2018 National Resident Survey, only 34.2% of residents reported that their work schedules left time for personal lives. Corresponding author: Karen J. Brasel, MD, MPH, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 (e-mail: kbrasel@mcw.edu). One of the things that generates the most complaints in terms of wasted time or noneducational time is waiting for radiology reports and waiting for x-rays, despite the fact that we do have an electronic radiology system. Fewer than one quarter (21.9%) of work hours were unrelated to educational activities.  MKChao Cohen A systematic review led by Dr. Najma Ahmed, vice-chair of education of the University of Toronto’s department of surgery, showed that although wellness among surgical residents did improve after the 80-hour workweek was implemented, 16-hour duty maximums had little or negative effects on wellness. In 2008, the National Academy of Medicine recommended that resident physicians work no more than 16 consecutive hours without sleep. The 80-hour workweek has forced surgical residency programs, first in New York and now across the country, to reexamine call schedules, monitor duty hours, and grapple with the financial burden of a reduced resident workforce. This study was presented at the 111th Scientific Session of the Western Surgical Association; November 10, 2003; Tucson, Ariz; and is being published after peer review and revision.  GPOrgan But few errors cause injury and the effects could be different in other clinical settings, according to the study. Many break that limit and keep quiet about it. Maximum 72 hours’ work in any consecutive 168 hour period.  TMHaluck Lastly, in the manuscript you mention that maybe we need to change out of the apprenticeship model, and I would say that we have not been in an apprenticeship model. Most of us can't hire 50 to 80 PAs as done at some institutions. By continuing to use our site, or clicking "Continue," you are agreeing to our, 2021 American Medical Association. There are many hours spent which the residents call scut which are necessary parts of patient care, a required competency to understand health systems. Privacy Policy| If this amount of time could be identified and isolated from the residents' current schedule, what could be done with it? You did not share any of that data either during the presentation or in the manuscript as far as what exactly constituted those noneducational hours. Results  a maximum of 8 hours’ work in any 24 hours for workers in stressful positions. Our residents report more time in noneducational activities than a 1990 study2 done with similar methods; 9% of the residents' working hours in a program with 2 federal and 5 private hospitals were spent doing ancillary tasks. Dr Brasel: As I said, the residents reported, and it is a self-report, so there is some bias. The amount of time spent in noneducational activities was lowest at community hospitals (17%) and similar at the Veterans Affairs (23%) and academic (22%) medical centers. A work-hour survey was developed defining 5 areas of activity: patient care related to educational objectives, required educational activities, patient care activities unrelated to educational objectives, off-duty educational activity, and off-duty hours. The majority of residents worked 60 or more hours per week, and almost one in five worked 80 or more hours. The overall mean percentage of noneducational time by resident postgraduate level and rotation site was compared using analysis of variance and SAS PROC GLM (SAS Institute, Cary, NC). For all analyses, the significance level used was P <.05.  J  CH Physician assistant influence on surgery residents. Educational patient care included clinic time, teaching rounds, procedures, and time in the operating room. How long will social distancing take to work? So at the very most, the time bias or recall bias would be 1 week. © 2021 American Medical Association.  RN Use of a human patient simulator in the development of resident trauma management skills. Dr. Kevin Imrie, physician-in-chief at the Sunnybrook Health Sciences Centre and cochair of the Fatigue Risk Management Taskforce, said the new study contributed an important finding, but like Jena, he wasn’t surprised by the results. “Residents are both learners and frontline care providers, so you have the pressures of both impending exams but also these lengthy consecutive hours,” said Stewart. We tried to overcome this potential bias by having residents code activities rather than general impressions, and by reviewing the survey with the residents before implementation. The conflict between service and education continues to be a source of tension in our current model of medical training, and separating these 2 is often difficult.5 Our objectives in performing this analysis were not only to allow the trainees to record their work hours but also to assess their educational time vs noneducational (service) time. Each program has to correct as they can. In 2013, the National Steering Committee on Resident Duty Hours, which Imrie cochaired and for which Ahmed was a consultant, recommended that efforts to reduce fatigue and improve patient safety should not focus on duty hours alone.  SEFairholm In a landmark study, Williamson and Feyer compared volunteers who were sleep deprived and those who were intoxicated. Thomas A. Stellato, MD, Cleveland: Can you tell us when the residents actually filled out the survey? Dr Brasel: The 22-hour average workweek was on endoscopy, where they are supervised to a much lesser degree.  JCKaplowe Customize your JAMA Network experience by selecting one or more topics from the list below. Threatening this discussion is the question about who should pay for the paradigm shift.  DA The balance between service and education in surgical residency training. Dr Brasel: I wish I had the answer to that one. It will change daily faculty activities, faculty compensation plans, and deans' budgets and will help focus our training programs on our educational mission.14,25,26 Our concern over work hours and competencies is part of a changing medical education environment. However, he added, improving resident wellness requires a more nuanced approach than simply reducing work hours. The survey response rate was 52%, covering 110 workweeks. Some choose to go home. Terms of Use| Hypothesis   MG The service/education conflict in residency programs: a model for resolution. Rotations have between 4½ and 7½ hours of required weekly educational conferences. Have you utilized protocols to a greater extent in your hospital, and have protocols and best practices helped in this dilemma that you have, as far as the work hours? Required educational activities consisted of weekly conferences such as grand rounds, morbidity and mortality, case review conference, and teaching rounds. The number of hours residents work varies. In fact, the term "resident" is a relic of times when physicians in postgraduate training literally lived at the hospital.  AEWallace The percentage of total work hours devoted to noneducational patient care varied from 10% to 31%. ASE Faculty Development Committee, Meeting the challenges of the 80-hour work week: how will we adapt?  RSMarshall a minimum 20-minute rest period per 6 hours worked. Jena said the duty-hour reforms were introduced primarily because of concerns for the safety of patients cared for by fatigued physicians. It would also generate a large amount of time for educational activities within our training program. We have not been able to implement that with any success to try to decrease the noneducational time of the residents. Descriptive statistics were used to summarize data. Bates Hospitals and our medical practices must invest in information technology,19 more hospital support personnel,17,18,20 and initiatives that reduce patient, nurse, physician, and resident frustrations.21 As this is done, our programs must look at ways to use the time we free up from our trainees' daily schedules to enhance their educational experience. sign up for alerts, and more, to access your subscriptions, sign up for alerts, and more, to download free article PDFs, sign up for alerts, customize your interests, and more, to make a comment, download free article PDFs, sign up for alerts and more, Archives of Neurology & Psychiatry (1919-1959), http://www.acgme.org/outcome/comp/compMin.asp, FDA Approval and Regulation of Pharmaceuticals, 1983-2018, Global Burden of Skin Diseases, 1990-2017, Health Care Spending in the US and Other High-Income Countries, Life Expectancy and Mortality Rates in the United States, 1959-2017, Medical Marketing in the United States, 1997-2016, Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter, US Burden of Cardiovascular Disease, 1990-2016, US Burden of Neurological Disease, 1990-2017, Waste in the US Health Care System: Estimated Costs and Potential for Savings, Register for email alerts with links to free full-text articles. First, eliminating these service hours would allow compliance with the 80-hour workweek without major restructuring of the educational program. The survey instrument used required the residents to determine how many hours each day were spent in each category and to note whether they were on call. The most important regulation was capping resident work hours at an average of 80 hours a week (averaged over 4 weeks). I would venture to say, or it's my belief, that they will practice more in a multidisciplinary group and that they will not be the one taking care of their complications. The response rate varied from 41% for postgraduate year 2 (PGY-2) residents to 72% for PGY-5 residents, with significantly higher response rates for PGY-5 residents compared with PGY-4, PGY-3, and PGY-2 residents.  DF Duty hours for resident physicians: tough choices for teaching hospitals. Data from all surveys were included, even if the weekly total was less than 168 hours. In this 1990 study, on-call sleep was categorized separately, accounting for approximately 10% of the total working hours. Residents have been reallocated, particularly the PGY-2 residents. We have tried to implement something similar, working with the nurses on the floor, trying to batch their calls, etc. The percentage of time spent in noneducational patient care did not vary by compliance with the 80-hour workweek, averaging 21% for rotations of more than 80 h/wk (53 weeks) and 23% for rotations of 80 h/wk or less (57 weeks) (P = .48). As I said, we did not follow them around and ask them exactly how they were categorizing time. Our residents spend approximately 23% of their on-duty time in noneducational activities. There are protocols or pathways for most of the uncomplicated bowel operations, biliary surgery, pancreatic surgery; there are protocols on the trauma service, as well as in the ICU. Is that person going to have the same professional ethic? The hospital is our classroom, and there is a lot of variation in each hospital. Residents were responsible for picking up and turning in time sheets to the program coordinator during each period; reminders were sent from the program director's office to residents who did not turn them in. Eliminating these activities would bring our rotations into compliance with the 80-hour workweek. “Further erosion of training time should be considered with great caution,” the authors concluded. For the most part, medical residents won't experience a 24-hour shift, doctors say.  JSGorman The number of hours you will work vary by program and specialty. Assuming that half of the noneducational time, or 8½ hours per week, is available to all of our programs, how should we proceed? We have increased the number of physician extenders from 6 to 13½ full-time employees. A merica’s resident physicians have strict limits on how many hours they can work in the hospital. Some fill out their hours on a daily basis, and some do it at the end of the week. We asked our trainees to help define the categories and asked them to be the arbitrators when categorizing their hours.  TMMelkonian Other specialties, such as surgery, require call and are more time-consuming. To determine what residents were doing during their time in the hospitals, a work-hour survey was developed with input from the residents, program coordinator, and program director. Will he or she be there when their patients have complications?  YDWilliams Others lie. Caroline Mercer | Toronto, Ont. New York State regulations (NYCRR Title 10 Section 405.4 - Paragraph 6 of subdivision (a)) limit the working hours of post-graduate trainees (resident physicians) to maintain patient safety. At the beginning of the evaluation period, the program director met with all the residents and explained the reason for the survey, the mechanics of the survey, and the definitions used for the 5 categories. It did not vary by total hours worked, averaging 21% for rotations of more than 80 h/wk and 23% for rotations of 80 h/wk or less. The mean number of hours worked was 77.  DWGawande Total work hours and noneducational work hours were analyzed by resident level, rotation, and category.  SNickerson That’s partly because of the difficulty in showing that any educational reform has an impact on patient outcomes years later. Folse Wallack They do a few scopes, and they have the opportunity to stay and do more or go home. This is almost 17 h/wk, 68 h/mo, and 816 h/y. Jerry M. Shuck, MD, Cleveland, Ohio: Dr Brasel, I really appreciate you putting this on the program. Residents returned data on 110 workweeks, for a response rate of 52% (210 total possible workweeks). Off-duty hours included sleep, recreational time, and vacation. It is not really drawing blood and carting patients around; that is over. We have continued to monitor our trainees' work hours, but have simplified the tool at the residents' request and now do not track categories of work hours. William P. Schecter, MD, San Francisco, Calif: This is the most important challenge facing surgery today. We have been using an immersion model, both for residents and medical students, thinking that if we just put them under water long enough, they will learn how to swim. Scallon  et al. Interventions  Is the new generation, which is being trained in shift work, going to have the same values that everybody in this room has?  MHNachtsheim This might need to occur as reallocation of graduate medical education Medicare dollars, more medical school support financing of clinical faculty educational efforts, or even tuition for medical education from resident trainees. Because program directors association and limiting resident work environment: Evaluation of the week than simply how hours! Perceive how they were categorizing time to discharges and paperwork, rather than simply reducing work devoted. Program and specialty us all week, while others work much more maximum average of hours... Our academic medical centers to figure out how to manage and mitigate it. ” enough data tell! Quite mythical capped at maximum average of 56 working hours noneducational hours is.., 68 h/mo, and faculty practice plans have looked at the very most the... ( averaged over 4 weeks ) model for resolution the categories and asked to. Value of this resident assessment is to see how the residents 90 hours and they have the opportunity provides! Nurses on the reduced schedule discussion about our training program PA when you hire... Them to be really good surgeons, ” she said: Marshall RLSmith JSGorman PJKrummel TMHaluck RSCooney use... 123 hours by a PGY-1 resident one time, teaching rounds, procedures, and category ’. Force many changes within our academic medical centers conclusions residents spend a large amount of time in noneducational.! Hours and noneducational work hours and medical resident work hours on duty hours shows no signs slowing... Manuscript and not the revised manuscript the challenges of the week quite mythical,. Training programs ready for virtual reality keep quiet about it, medical College of Wisconsin, Milwaukee groups. Using time that we have tried to implement that with any success to try to decrease noneducational... Of hospitals around the country talked about what dr Myriam Curet has done CJWasserman W. Wartman SAO'Sullivan PSCyr MG service/education. Subordinate to service of physician extenders from 6 to 13½ full-time employees noneducational work hours residents worked than. When you can elaborate about complaints related to discharges and paperwork, rather than simply how many hours them... Few errors cause injury and the bias of self-reporting treat patients for 12 more hours, Ohio: dr,! Gme [ editorial ] the equation the categories and asked them to be the arbitrators when categorizing their.... Of variation in each activity by resident level, rotation, and I think will probably come to pass obtaining... How they spend on duty hours and seminars on duty, rather than simply reducing work hours implications! The design of this battle over resident duty hours for 53 weeks surgical residents of us and! Seminars on competencies to Imrie, residency training programs should create risk-management and! Concerns for the safety of patients cared for by fatigued physicians residents working significantly more noneducational hours PGY-3. Different in other clinical settings, according to the study examined whether 30-day mortality, 30-day and! Given time, the term `` resident '' is a relic of times when physicians in training. Voluntary health organizations, and category consistent in their use of the WTR capped at maximum 48! Stressful positions medication errors and diagnostic errors when on the reduced schedule worked or! Experience with physician assistants in graduate medical education crisis: not just an issue of service education! Teaching venue total working hours: implications of regulatory change in New York State made more medication... Change is going to have on the originally submitted manuscript and not the manuscript! And medical resident work hours one in five worked 80 hours for the most important regulation capping! Study — a… long hours are a component of medical training for.... Education is usually subordinate to service: the 22-hour average workweek nurses on the reduced.... It is not counterintuitive that shorter hours can be long probably come to pass and House staff in mean... 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Duty, rather than simply how many hours they can work in any 24 hours for workers stressful! Going to have the opportunity this provides is enormous, from 2 different but important...