• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Resident Work Hours To AMSA National 2005
 

Resident Work Hours To AMSA National 2005

on

  • 681 views

1-hour presentation to medical students on resident work hours, sleep medicine

1-hour presentation to medical students on resident work hours, sleep medicine

Statistics

Views

Total Views
681
Views on SlideShare
681
Embed Views
0

Actions

Likes
0
Downloads
0
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • What year in med school is everyone in? How many of know a resident personally? How many of you consider yourself knowledgeable about RWH? Not enough. NEITHER extensive knowledge of studies NOR having gone through residency is enough. We’ve had pretty good knowledge until now. Arguably, residents 15 years ago were more tired than we. We need ACTION. Residency is a time of learning. It’s a time for service too, but it’s a formative time in one’s professional and personal development. People who make it through residency ‘intact’ are much better off than those who do not. The problems is that residents don’t have time to fight this fight. Medical students don’t really have the time either, but improving awareness in medical school will slowly change the culture of residency as successive classes of students graduate into residency. Goal Resident perspective – Medical student perspective is limited. Outline The Problem Residency culture is hard to change. It’s actually easier for programs to work residents longer (signout, inefficiencies, cheaper) Errors Theoretical: BAL Studies, Epworth Alertness Problem is that residents cannot judge when they are fatigued. Actual: Resident Health Pregnancy Errors What you can do Residency Program Selection “ The Culture of Medical Education”
  • FORMERLY SLIDE 31 Due to physiology of circadian rhythm and the fact that with progressive sleep loss, chronic sleep loss increases sleepiness while subjective ability to quantify fatigue decreases.
  • FORMERLY SLIDE 32 Self-evaluation is generally poor among residents.
  • FORMERLY SLIDE 5 Survey and clinical outcome studies have demonstrated that in generally physician education regarding basic sleep and circadian biology and clinical sleep disorders is inadequate. This knowledge deficit persists through all levels of medical education. Despite the high prevalence of sleep disorders, it is hypothesized that the vast majority are undiagnosed presenting as a high public health burden in resource mis-utilization, morbidity, lost hours of productivity at work, etc. The culture of medicine says: “ Sleep is “optional” (and you’re a wimp if you need it)” “ Less sleep = more dedicated doc”
  • FORMERLY SLIDE 5 Survey and clinical outcome studies have demonstrated that in generally physician education regarding basic sleep and circadian biology and clinical sleep disorders is inadequate. This knowledge deficit persists through all levels of medical education. Despite the high prevalence of sleep disorders, it is hypothesized that the vast majority are undiagnosed presenting as a high public health burden in resource mis-utilization, morbidity, lost hours of productivity at work, etc. The culture of medicine says: “ Sleep is “optional” (and you’re a wimp if you need it)” “ Less sleep = more dedicated doc”
  • Has anyone here heard of anecdotal evidence that support a relationship between work hours and fatigue? Of course. Everyone has.
  • FORMERLY SLIDE 10
  • FORMERLY SLIDE 6 Residents report routinely levels of sleepiness which are comparable to having a primary sleep disorder. The Epworth Sleepiness Scale is an 8-item, self-reported tool that asks respondents to rate their likelihood of dozing off under several specified conditions. Rating is 0 to 3 where 3 is most likely to doze off. Scores are totaled. ULN is 11. 11-13 is mild. 14-17 is moderate. >17 severe.
  • FORMERLY SLIDE 13 The circadian rhythm is intrinsic; it’s an adaptive behavior that we have acquired that helps us to avoid predators. Morning people generally have a hard time adapting to late shifts whereas night people can usually adapt to morning shifts.
  • FORMERLY SLIDE 14 You’ve all heard of circadian rhythms. Basically the circadian rhythm refers to the intrinsic physiologic processes that run in a cycle of just over 24 hours. The circadian sleep rhythm is modulated by the hypothalamus (suprachiasmatic nucleus) which derives its input from environmental cues including light, activities. This is evidenced by cyclic body temperature. Homeostatic drive builds up during wake and counterbalances the circadian system that facilitates awakening.
  • SLIDE 12 Hypnograms, graphic representation of sleep stages vs. time. Non-Rem = low brain activity, body movements preserved. Stage 1 (2-5%): Light sleep Stage 2 (45-55%): Initiation of true sleep, bursts of rhythmic rapid EEG activity called sleep spindles Stage 3 & 4 (3-23%): Deep sleep (aka slow wave or delta sleep). This is the restorative type of sleep. Hardest to be awakened during these stages. As sleep is restricted, this is the stage that the body preserves (i.e., with chronic sleep deprivation this is the stage that attains the highest proportion during sleep when recovery sleep is permitted) REM (20-55%, 4-6 episodes per night). Paralysis. High levels of cortical activity. Dreaming. Irregular respiration and HR. Eye movements. Each cycle lasts 90-110 minutes (4 – 6 per night). CLICK This is what the hypnogram of a resident on call might look like. The red arrows denoted pages (they’ve actually done this study!). As you can see, with each interruption, the subject is not allowed sufficient time to descend into the restful Stages 3 & 4, resulting in a normal “amount” of sleep but not the correct type and thus morning fatigue.
  • This famous study showed that long hours of wakefulness, which would be common on a routine resident call shift, leads to a dose-dependent decline in cognitive psychomotor performance, in the same way that increasing blood alcohol concentration impairs functioning. All of these regressions are statistically significant (R 2 =0.69, P<0.05 on the right, for the statistically curious). This study used a computer-administered hand-eye coordination task (an unpredictable tracking task) as the measure of performance. The one caveat is that the lines look identical but on the right, the y-axis is scaled a little differently. Nonetheless, by looking at a level of 0.94 for mean performance (y-axis), you can see that that corresponds to 24 hours of wakefulness on the right, and corresponds to a BAC of about 0.08, the statistical range for which includes 0.1 (next slide).
  • In fact, 24 hours of constant wakefulness reduces cognitive psychomotor function to a level equivalent with having a blood alcohol level of 0.10 2. A resident who has been up for 24 hours is essentially drunk—who wants to be treated by somebody in this state? 3. There is a slight rebound with improvement of performance after 24 hours, but look at how many hours of impairment somebody must endure to get back up!
  • SLIDE 19 Surgery: two recent simulated laparoscopy studies found significantly more errors and more time to perform procedures with increasing sleep loss, mornings post-call, irrespective of level of training. 20% more errors, 14% more time. Internal Medicine: first/second year residents vs. third/fourth year residents Efficiency and accuracy of performance on interpretation of ECG deteriorated post-call which persists into senior years suggesting that there ISN’T adaptation to sleep deprivation Pediatrics: Performance on board-type questions, intubation, IV and arterial catherterization  found significant differences after 24 hours and 36 hours of continued wakefulness.
  • That was all theoretical…is there real evidence that any of this makes a difference?
  • 1. Residents could list more than one factor (so there is some overlap between the fatigue and job overload responses)
  • Study of twenty internal medicine interns in MICU or CCU at large academic teaching hospital.
  • A case study of 14 residents at Columbia Presbyterian Hospital illustrates the alterations in mood and affect experienced by residents as a result of fatigue and sleep-deprivation. [27]   In this study, residents were on-call every other night, and often worked 60-hour shifts.  The following are comments taken directly from study subjects, all of whom experienced mood alterations:  Difficulty Concentrating.   “When I'm tired, even though my mind is active, I can't concentrate.  I can't put things together in my mind so I don't even try.  If a patient is really sick, I can pull myself together but I can't write down what I've done in the chart.  What I write is a reflection of a fragmented thought process…. It gets me scared when this happens because it means that I am losing control of my ability to think.”   Depressed Mood.   “My home life suffers and I miss my wife greatly.  I feel ashamed that I get tired and can't live up to the tradition of the ‘iron men.'” Irritability.   “As I lose sleep, I get more explosive and more irritable.  I snap at nurses and make them cry.  I pick on the nursing staff rather than my wife or my patients.  I'm ashamed of it in a way.”  “If you're on two nights in a row, you want to do as little as possible.  You give bad care.  I am irritated all the time then … I give bad care to my patients, unfortunately.  When I'm tired I don't give a Goddamn.”  Inappropriate Affect (“Black” Humor).   “I laugh at things that aren't really funny.  I'm giggly when I'm tired.  For instance last night a patient came in comatose.  Another intern asked the patient: ‘Do you have any parakeets at home?'  I found this enormously funny and I laughed and laughed … Things don't seem so funny to me when I am rested.  Another example of my sense of humor when I am fatigued would be: An intern gets a patient with congestive heart failure and pulmonary edema.  He makes a wise comment like, ‘Give her some vitamins and send her home.'  That makes me crack up.  I would not find such a remark funny when I am rested.” Memory Deficit.   “I would forget what I just said so my next sentence would make no sense.  I also stop sentences midway a lot because I forgot what I wanted to say.”  Other studies confirm these mood effects using objective measures.  Researchers at Case Western Reserve University compared 34 pediatric residents before and after a night of call with 27 residents who were not on-call either day. [28]   The different groups were tested using the Profile of Mood State scale (POMS), a 65-item adjective-rating measure that assesses mood state on a five-point scale.  A total score is provided, as well as subscales for tension-anxiety, depression-dejection, anger-hostility, vigor-activity, fatigue-inertia, and confusion-bewilderment (higher score = worse mood state).  The on-call group of residents showed increased total negative mood state scores (pre-call: 54, SD 22; post-call: 74, SD 29), while the group not on-call any of the days demonstrated improving total mood scores (Day 1: 60, SD 33; Day 2: 49, SD 27).  The scores for all six subscales of the POMS also demonstrated increased negative mood for the on-call group post-call, while the off-call group demonstrated improved mood on the second day.  The consistent results of the subscales suggested that call duty affects a broader array of psychological responses than simply fatigue.  The authors observed: “Our findings are consistent with anecdotal reports of the effects of call… The fact that number of hours slept correlated with increased negative mood state, anxiety and perceived stress suggests that sleep deprivation affected psychological state.” In another study utilizing the POMS, researchers compared 16 randomly recruited residents (8 males and 8 females) before and after 32-hour shifts at St. James Hospital in Dublin. [29]   The investigators found that the total POMS mood score significantly deteriorated post-call, from an average of 3 pre-call to 37 post-call (p < 0.0021; again, higher scores being worse).  The difference in depression-dejection score was not found to be significant comparing before call to after call; however, the investigators noted: “The lack of significance in the depression rating must … be treated with caution as the total mood disturbance score, which has been shown previously to correlate well with general psychological well-being, showed a marked deterioration after the period of duty in our subjects.”  Moreover, the study had a very small sample size. German researchers performed psychological testing on 40 residents at the University Hospital in Tuebingen, who averaged 3 hours of sleep on call.  Subjects were tested in the morning after a night off-duty (with at least 6 hours of uninterrupted sleep), and once more at a similar time in the morning after a night on-call (24 continuous hours worked in the hospital).  Scores for emotional state tested via a 28-pair mood-adjective list were considerably worse for the post-call group compared to the off-call group (60, SD 9 vs. 54, SD 7; 2 points were assigned per negative adjective, 0 for positive adjective, and 1 for neither/nor).  The researchers noted, “[T]he emotional condition worsened after one night on-call with the following negative adjectives having been reported most often: tired (32 residents), feeble (24), tense (20), hesitating (15), lacking in verve (15), restless (12).” [30]   Another study randomly assigned 30 first-year internal medicine residents to sleep-deprived (n = 16) and nonsleep-deprived (n = 14) groups, and followed them from the fifth to the ninth month of their internship year at the Medical College of Virginia Hospitals.  The two groups had similar ages, sex ratio, and racial composition.  Residents in both groups were tested with the Multiple Affect Adjective Check List (MAACL) from 2 –3 pm after being on-call or after having been off-duty.  Sleep-deprived residents (mean 2.7 hours sleep) reported greater mood disturbance than the nonsleep-deprived residents (mean 7.9 hours of sleep) in the different categories of the MAACL (p < 0.05). [31]   In another study at Columbia University, investigators used the Nowlis and Green Mood Adjective Check List (MACL) to compare 14 interns when rested and fatigued.  The MACL consisted of 33 adjectives describing 11 mood factors: aggression, anxiety, surgency (feeling carefree, lively, talkative), elation, concentration, fatigue, social affection, sadness, skepticism, egotism, and vigor.  In the 32 hours before testing, rested interns slept a mean of 7.0 hours and fatigued interns slept a mean of 1.8 hours (p < 0.001).  Once more, tired residents reported worse scores than rested residents, with tired residents having statistically lower scores in positive mood factors (surgency, vigor, elation, egotism, and social affection) and significantly higher scores in negative mood factors (fatigue and sadness). [32]   Studies thus consistently show that medical residents experience negative, unhealthy alterations in mood as a result of their long work shifts.  The authors of a comprehensive review of the effects of sleep deprivation on residents concluded that the “accumulated evidence of studies performed over the past 30 years … suggests that the traditional system of 100-hour work weeks and 36-hour days may do harm.  Clearly, residents' moods, affects and attitudes are altered unfavorably.” [33]  
  • Distinct from depressed mood is depression, a clinical term requiring that at least five of nine defined criteria are met for a period of at least two weeks.  One of the five signs must include either depressed mood or anhedonia (loss of interest/pleasure in life), and the other four can include appetite disturbance with weight change, sleep disturbance, psychomotor disturbance, fatigue or loss of energy, feelings of worthlessness or guilt, diminished ability to concentrate, and recurrent thoughts of death/suicidal ideation. [34]   High rates of depressed mood place medical residents in a higher risk group for developing clinical depression.  Indeed, as many as 30% of medical residents experiences depression at one time during their residencies. [35] Female physicians have been shown to be especially vulnerable. [36]   Applying the MeSH terms “Internship and Residency,” “Work Schedule Tolerance,” and “Sleep Deprivation” to the MEDLINE database yielded the following two studies.  In a study utilizing the Center for Epidemiological Studies-Depression (CES-D) scale, a predictor of depression, investigators surveyed 68 medical house officers at Rhode Island Hospital. [37]   They administered the test on a monthly basis for a year, with a response rate of 83%.  Twenty-one percent of respondents reported “depressed” scores, defined as a CES-D score equal to or greater than 16 (on a scale of 0 to 60).  When classified by year, 29% of first-year residents, 22% of second-year residents, and 10% of third-year residents reported depressed scores (p < 0.0001).  (Resident work schedules typically improve as residency progresses.)  When responses were examined by rotation (the specialty in which resident is currently working), depressed responses were most frequently received during those rotations that routinely required over 80 hours of work per week.  Twenty-five percent of residents reported depressed responses while on ward rotations, and 32% while on the intensive care unit, both of which require over 100 hours of work per week.  The author concluded, “The increased frequency of depressive symptoms on ward and intensive care rotations may be, in large part, caused by long working hours and sleep deprivation.” In a study at two hospitals in St. Louis, investigators interviewed 53 interns at the end of their first year of training. [38]   Based on the Feighner criteria for clinical depression, 16 (30%) had an episode of depression during their internship, of which 13 were definite depressions and 3 were probable depressions.  The depressed and non-depressed groups were very similar in terms of age, sex, marital status, and type of internship.  Medical, social, and childhood histories were likewise not significantly different.  Eleven of the 16 interns became depressed within the first few months of their training.  Four of the 16 had suicidal ideation, 3 had a suicidal plan, and 6 experienced marital problems for the first time.  One subject who had made a suicidal plan thought of 5 or 6 ways to kill himself so that his wife could collect insurance.  Six depressed interns had feelings of hopelessness, 2 had a fear of losing their minds, and 3 called their spouses while on night call, crying, and saying they couldn't go on.  Of the 11 whose depression began in the first two months, 7 were working more than 100 hours per week.  Of the 5 who became depressed later in their internship, 3 were working more than 100 hours per week at the time of the onset of their depression. In sum, while it is certainly possible that the difficult nature of the medical work in residency contributes to the development of depression, evidence for the large role of excessive work hours is strong.  Fatigue and sleep deprivation caused by excessive work hours contribute to depressed moods in residents, placing them in a high-risk group for developing clinical depression, in turn increasing their risk for suicidal ideation/suicide.  Experts have agreed, “This combination of stress and fatigue may lead to severe psychologic repercussions, which may first appear as disappointment, loss of idealism, and isolation, and then progress to feelings of helplessness, impaired performance, and outright depression.” [39]   The authors of another study concluded, “In view of the special vulnerability of medical trainees to occupational stress, all efforts are warranted to reduce sleep deprivation in the medical profession.” [40]   It is reasonable to expect that reducing work schedules to allow for more sleep should reduce both the incidence of depressed mood and the likelihood of developing depression. 
  • FORMERLY SLIDE 24 Same study from slide 22 Random survey of PGY1 and PGY2 in 98-99 – 3604 respondents (64.2% response rate):
  • In the best-designed investigation, Klebanoff et al. sent questionnaires to 5096 female physicians who had graduated from medical school in 1985 and a random sample of 5000 of the 12,306 male physicians who graduated the same year. [44]   Eighty-seven percent (4412) of the women residents and 85% (4236) of the wives of male residents responded to the questionnaire, which included questions on outcome of each pregnancy and number of hours worked.  Women residents reported working twice as many hours per week during their pregnancies as did the wives of the male residents.  Between the two groups overall, investigators found no statistically significant differences in the proportion of pregnancies that ended in miscarriage, ectopic gestation, stillbirths, preterm delivery, or intrauterine growth retardation.  However, three important findings were identified.  First, premature labor requiring bed rest or hospitalization was nearly twice as common among the women residents as among the male residents' wives (11.3% vs. 6.0%, p < 0.001).  This finding supports the similar finding of the Osborn study.  Second, preeclampsia or eclampsia was also twice as common among the women residents as the male residents' wives (8.8% vs. 3.5%, p < 0.001).  Third, for those residents working 100 or more hours per week during the 3rd trimester, there was more than twice the risk of preterm delivery compared to those working fewer than 100 hours (10.3% vs. 4.8%, p = 0.04).  Premature labor, preeclampsia/eclampsia, and preterm delivery (in women residents working over 100 hours), were thus found to be significant problems for the pregnant residents.  Klebanoff et al. commented, “This increase suggests that the New York State law limiting residents to 80 hours of work per week is well advised with respect to pregnant residents.”   Using the same data set, Klebanoff et al. also compared early-pregnancy complication rates in female resident physicians with those among partners of male resident physicians. [45]   The life-table probability of spontaneous abortion was 14.8% for female residents and 12.6% for the partners of male residents (RR 1.18, 95% confidence internal 0.96 – 1.45), a difference that was not statistically significant. In another survey, investigators surveyed 1025 female board-certified obstetricians about their pregnancies before, during, and after residency. [46]   The response rate was 49%.  The mean number of hours worked during residency was 78.9, compared to 36.4 before residency and 46.5 after residency.  The average birthweight of firstborn infants delivered during residency was found to be significantly lower than the birthweight of firstborn infants delivered before residency (3146g, SD 696 vs. 3525g, SD 455, respectively; p < 0.001).  Although mean birthweights were lower in infants delivered after residency (3263g, SD 556; p < 0.005), they were still lower than birthweights of infants born before residency.   The low birthweight rates (defined as any birthweight below 2500g) were 3.7%, 11.6%, and 2.6% before, during, and after residency, respectively.  A second critical finding was that infants delivered during residency were more likely to be born with intrauterine growth retardation (defined as birthweight that was under the 10th percentile for a given gestational age) than those delivered before or after residency (rates of 1.2%, 8.2%, and 1.0%, before, during, and after residency.) In summary, the results of the best-conducted study with the largest sample size point to increased risks for preterm labor requiring serious hospitalization, preeclampsia or eclampsia, and preterm delivery in those residents working greater than 100 hours a week.  A second paper with a large sample size suggests that residents and their children can also suffer from decreased birthweights and intrauterine growth retardation.  The author of one study agreed that available research includes “sufficient findings to suggest that heavy exertion and fatigue may cause premature deliveries, decreased birthweights, and other complications in pregnant residents.” [47]   In a review of the literature on pregnancy complications of medical residents, another author concluded, “[T]he greatest factor leading to poor pregnancy outcomes among physicians seems to be time spent working, particularly during late pregnancy.” [48]   The signers of this petition believe that even modest work-hour limitations would significantly reduce these adverse outcomes. 
  • In another survey, investigators surveyed 1025 female board-certified obstetricians about their pregnancies before, during, and after residency. [46]   The response rate was 49%.  The mean number of hours worked during residency was 78.9, compared to 36.4 before residency and 46.5 after residency.  The average birthweight of firstborn infants delivered during residency was found to be significantly lower than the birthweight of firstborn infants delivered before residency (3146g, SD 696 vs. 3525g, SD 455, respectively; p < 0.001).  Although mean birthweights were lower in infants delivered after residency (3263g, SD 556; p < 0.005), they were still lower than birthweights of infants born before residency.   The low birthweight rates (defined as any birthweight below 2500g) were 3.7%, 11.6%, and 2.6% before, during, and after residency, respectively.  A second critical finding was that infants delivered during residency were more likely to be born with intrauterine growth retardation (defined as birthweight that was under the 10th percentile for a given gestational age) than those delivered before or after residency (rates of 1.2%, 8.2%, and 1.0%, before, during, and after residency.) In summary, the results of the best-conducted study with the largest sample size point to increased risks for preterm labor requiring serious hospitalization, preeclampsia or eclampsia, and preterm delivery in those residents working greater than 100 hours a week.  A second paper with a large sample size suggests that residents and their children can also suffer from decreased birthweights and intrauterine growth retardation.  The author of one study agreed that available research includes “sufficient findings to suggest that heavy exertion and fatigue may cause premature deliveries, decreased birthweights, and other complications in pregnant residents.” [47]   In a review of the literature on pregnancy complications of medical residents, another author concluded, “[T]he greatest factor leading to poor pregnancy outcomes among physicians seems to be time spent working, particularly during late pregnancy.” [48]   The signers of this petition believe that even modest work-hour limitations would significantly reduce these adverse outcomes. 
  • SLIDE 27 In studies that actually looked at performance on educational tasks, results are mixed. Surgery log books In general, studies suggest that trainess may be able to compensate for short time but motivation and satisfaction are greatly diminished.
  • SLIDE 22 Random survey of PGY1 and PGY2 in 98-99 – 3604 respondents (64.2% response rate): Reported working average of 79.4 hours per week and sleeping less than 6 hrs per night. In this study, residents who worked longer hours and averaged fewer hours of sleep reported committing significantly more serious medical errors, conflicts with attendings, nurses and other residents.
  • This paper found that residents themselves described their own interactions with patients and family members as inattentive and abrupt, as a result of fatigue; obviously, residents realized they were not behaving with a professional demeanor
  • SLIDE 21 Profesionalism compromised. “ More difficulty listening, emotionally unavailable, being more direct, less patient” Compassion in post call clinic compromised.
  • This table is designed to show that the proposed federal legislation in many ways is better than the ACGME regulations—it’s a bit much but there’s a lot of important info here The European Working Time Directive is the guidelines passed by the EU for all EU doctors-in-training; since their system is a bit different from ours, I didn’t look up all the bits and pieces, but the gist of it is there. It was originally passed years ago, but for residents the first real firm guideline was the reduction in work hours to 58/week by Aug 2004, then it will go down to 48 by 2009. Point out: Compared to Europe, we’re still working a ton! No averaging of work hours in the proposed federal legislation (for max hours, on-call frequency, mandatory off-duty time) No whistleblower protections in ACGME regs Possible loss of accreditation as a penalty under the ACGME regs The previous two points mean that under-reporting of violations is very likely right now! No public disclosure of violations under ACGME regs No additional funding for ancillary staff under ACGME regs—this means that hospitals are forced to reduce resident hours but without any way to compensate—med students might end up being exploited because of this!
  • Formerly slide 45 Ytypically drowsy driving crashes involve a single occupant driving off the road. Risk factors above Arrows denote when most people drive home (partly sampling bias), but these times nonetheless denote the nadirs in circadian rhythm.
  • ?slide 44
  • SLIDE 36-38? Prophylactic naps brief nap prior to 24 hours of work improve alertness during that 24 hours. Therapeutic naps Frequent brief (i.e., 15min) naps mitigate decline in performance. Maintenance naps 2-8 hour nap before work Sleep inertia : most likely upon elicited arousal from deep sleep, characterized by slowed speech, substantial performance deficits, poor memory and impaired decision making. Very little is known about sleep inertia and answering pages at night.

Resident Work Hours To AMSA National 2005 Resident Work Hours To AMSA National 2005 Presentation Transcript