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Can the profession effectively self-regulate residents' duty hours?

Thomas Nasca, MD, MACP, the CEO of the Accreditation Council for Graduate Medical Education, has written an open letter to the GME community on the work of the ACGME task force charged with responding to the Institute of Medicine's recommendations on duty hours.

A draft document will be presented to the ACGME Board in February 2010, with anticipated implementation of the new standards by July 2011. Dr. Nasca writes that the new standards "will require the commitment of the profession to implement effectively," as well as sacrifice, "courage to monitor and self-regulate and honesty of all in the accreditation process."

He concludes, "Anything less will, likely, result in the removal of the right of self regulation of this dimension of the education of future physicians from the control of the profession."

We asked readers of the GME e-Letter for their feedback on this letter and the concerns raised by Dr. Nasca.

Dr. Nasca's very thoughtful letter on duty hours policy highlights that this is indeed a very complex issue. But I was disappointed that he did not address the issue of data accuracy with respect to duty hours reporting.

In the hospital in which I work, I am aware of at least one department that is in gross violation of the duty hours requirements, and its policy of resident intimidation ensures that this problem remains confidential. I can almost guarantee that this situation is not unique. 

For this particular department, data collection of resident duty hours is extremely inaccurate. Residents are told, "It is your responsibility to ensure that documentation of duty hours complies with the ACGME guidelines." When junior residents in this department report actual hours worked, the department head has been known to request the senior resident's presence in his/her office to clarify this policy. "It is your responsibility to ensure that person A, B and C comply with the ACGME duty hour rules. You need to be more efficient." The implicit message is clear.

As a result, documentation complies because accurate reporting would raise concerns for accreditation. The residents, of course, are extremely invested in ensuring that their program remain accredited, because graduation from an unaccredited program reduces employment prospects, particularly if the departmental faculty ascertain that the problems with accreditation were linked to a particular resident who chose to document duty hours accurately. In theory, duty hours reporting is anonymous. In reality, for very small programs, every data point entered is tracked, and the person entering that piece of data is easily identified.

Hours in the hospital are only the beginning. Activities such as clinic notes and operative dictations are completed in "free time." Home call, journal clubs, ethics discussions, M+M preparation and attendance, providing transportation from and to the airport for visiting professors and fellowship applicants, medical school applicant interview dinners (at which the residents dutifully profess perfect satisfaction with the program), mandatory research projects--the list goes on. So a true accounting for all the time spent in work-related service would regularly exceed 100 hours per week.

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I agree with the draft letter of the ACGME.

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The ACGME is following a path that is leading to the destruction of graduate medical education. I have 30 years of experiencing teaching in academic medical centers. The residents are just as smart now as they were 30 years ago but they are incapable of doing a complete history and physical examination and so inexperienced and lacking clinical judgment that I am forced to manage many of the cases they admit.

I already learned how to do this. When will they?

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Dr. Nasca writes that the new standards "will require the commitment of the profession to implement effectively," as well as sacrifice, "courage to monitor and self-regulate and honesty of all in the accreditation process."

"Anything less will, likely, result in the removal of the right of self regulation of this dimension of the education of future physicians from the control of the profession

This quote could be interpreted or imply that we in the profession are not currently capable of implementing effectively, sacrificing, monitoring, self-regulating, and being honest in the accreditation process. Is that right? I believe that is not what he wishes to convey, but it is an annoying challenge to those of us who believe that we have devoted a lifetime to medical education and we possess the qualities of effectiveness, sacrifice, dedication, discipline, and honesty, etc, etc.

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The duty hour regulations need to be rewritten so that they are much more mindful of the different needs of different specialties. Also, RRCs in the past have often had very little evidence for some of their mandates, which often restrict flexibility and innovation in the structure of residency education. I fear the same pattern will be followed with duty hours. It’s one thing to say that tired residents make errors. It’s quite another to mandate certain changes without evidence that such mandates result in less errors. Simply having good intentions is not good enough.

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Dr. Nasca’s letter is truly one of the most considerate letters I have ever reviewed. He does an excellent job pointing out that there is a balance between optimal education and optimal work hours. In Malcolm Gladwell’s book Outliers, the author reports that a minimum of 10,000 hours is required to achieve expertise in a field. As physicians, we certainly owe our patients a health care field full of experts, which will require at least a minimum number of hours.

I would like to especially support three of the points discussed and relate my personal experience.

  1. I was trained as a cardiothoracic surgeon, prior to the implementation of duty hours. The system was abusive and inhumane. That being said, it did train me, like a marathon runner, for those long periods where it is necessary to work with limited rest (the aortic dissection, heart transplantation, the middle of the night cardiac case). Although we certainly should have had a better balance in my training experience, endurance for patient care is a critical facet of training that must not be lost.
  2. We must recognize that despite their many similarities, the fields of medicine are quite different and the responsibilities (in particular the time requirements and flexibility as an attending) are also quite different. Residencies vary in length (internal medicine is three years, general surgery five years, etc.); why should we try to standardize work hours across all fields?
  3. Medicine is a field that understands delayed gratification perhaps better than any other. We sacrifice our youth and many of our prime earning years for the privilege of practicing medicine—a trade-off that is well worth it. Our approach to health care should be in the same tradition. I hope that in the future, we provide our residents with a training system that is superior to that of the past. The goal must be continued improvement in health care. Any training system that produces a lower-quality resident is a failure. A physician practices for more than three times the number of years spent in training, so the negative effect of inadequate training will be detrimental to an even greater number of patients in the long run. No matter how residents’ hours are structured, we need to make sure their education is improved.

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Resident duty hours continue to raise concerns. A major issue here is the concept of education versus service. Those who raise the issue of "cost" basically do so from the perspective of the service provided by residents rather than their education.

Another issue is the actual number of hours on duty. Certainly there needs to be balance between adequate rest to promote safe and high-quality care and being on duty sufficient time to acquire experiential learning. One approach is to shelve the concept of 80 hours, replacing it with a maximum shift length of 16 hours in any 24-hour period. This could contribute to rested learners who also should be able to provide safer care.

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It is a well-known fact that extended hours of work without sleep cause a decrease in cognitive ability. Every resident has experienced this. Duty hours for U.S. residents need to be reduced, as has already occurred in Europe.

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Having been a resident myself and worn out my beeper doing calls, I can say that that extended work hours resulted in more falls and therefore incident reports filed and CT scans and perhaps even future litigation. In addition, residents have died in car crashes on their way back home after duty. Research shows that most accidents occur among people who work through the night and not even 16 hours at a stretch. One may function at near-peak performance in the hospital due to academic and clinical pressures, but the impact of long hours on one’s personal life is real, and we in medicine, as the most caring part of society, should take action on this issue. 

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One comment on duty hours points out the need for enough time to become an expert—10,000 hours, according to one source. Assuming an 80-hour work week, and 49 weeks of work per year, that's near 12,000 hours of training for a three-year residency. Should be enough. May not be, but at least gets one over the 10K mark.

Now consider a 50-hour work week, the European standard for housestaff. That works out to approximately 7,000 hours over three years.

If we reduce duty hours, the residents will be rested.

They will also be ignorant.