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What do you think about the IOM report on duty hours?

In the December 2008 issue of the GME e-Letter, we noted that the AMA’s support for the 80-hour weekly limit on resident duty hours was reinforced by the recommendations of a new report from the Institute of Medicine (IOM).

In response, we received the following e-mails from e-Letter readers (each respondent’s identifying information has been removed).

Medical education a "disaster"

I have been teaching internal medicine to medical students and residents for nearly 40 years, and I have two children who are physicians, so I have lots of personal experience with housestaff training. What I am telling you is based on my personal observations and from discussions with colleagues in other disciplines, such as neurology and surgery.

To put it simply, the current system of medical education is a disaster. The residents we train are still smart and dedicated individuals but they are not being properly educated to care for patients. I am shocked at how little experience even third year residents have. The system has shifted the responsibility for patient care from the residents to attendings. Many teaching institutions have hired hospitalists because the residents can no longer handle the patient load due to restrictions on hours and numbers of patients on a team, etc. Hospitalists make all the important decisions. This turns the residents into passive observers. Much of their so-called education is from lectures and conferences rather than direct patient care. This is the European system of medical education, and it is an inferior method of educating physicians. The so-called studies of residents do not judge whether they know how to care for patients. Being able to answer Board questions is important but not a substitute for learning clinical judgment. If patients have not been injured by these so-called reforms it is because attendings have taken over for residents. My fear is what will happen when these trainees do not have attendings shoring them up, telling them what to do. My data is anecdotal, but it is consistent. Experienced physicians in practice are shocked at the gaps in knowledge of their young colleagues.

I despair that we will ever go back to demanding more from residents (they now work many fewer hours than most general surgeons work in private practice). The only hope for their education is to extend all residencies by at least another year. Hospitals are already having trouble paying residents, however, so this would not be accomplished easily.

This whole movement was initiated by Libby Zion's unfortunate death in a teaching hospital. Everyone who has reviewed that case agrees her death was not caused by overwork or fatigue on the part of the intern and resident involved. It has taken on a life of its own, with well-meaning individuals outdoing each other to be "kind" to the residents. It is time to step back and look at the real consequences of what we are doing. I was once told by a Chinese physician to avoid anyone who was trained in medicine during the Cultural Revolution. I now tell people the same thing about our current crop of physicians.

Further limits well-intentioned but misguided

Yet more limits on duty hours?
 
There are no limits for us in our 50s, we who trained 25 years ago.
 
Our trainees will soon be in practice, where there are no limits on duty hours. Where they will have to know how to function when they are tired.
 
Limits on duty hours may be well-intentioned, but they are misguided.
 
We must chose between experienced, knowledgeable, but tired docs, and well-rested ignorant ones.
 
I'll take a tired doc who is functioning at 80 percent, rather than a rested one, whose ignorance makes her a zero.

Recommendations disregard difference between surgical and nonsurgical specialties

The reaction of the American Association of Neurological Surgeons/Congress of Neurological Surgeons to the report is not as positive as that of the AMA or others; we believe many of the recommendations clearly disregard the differences between surgical and nonsurgical specialties.

In the long run, patients will suffer

What a disgrace the IOM report is to the ethical responsibilities for training new generations of physicians. Ultimately, the public will pay, with physicians who are no longer devoted to caring for them above their own selfish interests. The AMA’s endorsement of such a stance just makes me sad.

Allow more flexibility for teaching hospitals

My plea is to allow each institution to establish its own rules for coping with the 80-hour week and resident fatigue (and by the way, do not omit medical student fatigue from the discussions). Universal, central ACGME control does not constructively help every training site. I believe a responsible institutional leader should simply sign a form each year stating "our medical center's training programs are in compliance with the 80-hour work week." Integrity, a paramount professional behavior, will therefore be honored, and this "role-modeling" will help encourage professional behavior.

No evidence of patient safety or educational benefits

While I'm in staunch support of efforts to improve the training experience, those of us in the trenches are still waiting to see evidence that patient safety and/or resident education has been enhanced by the last round of duty hour changes. Several of us see problems with inpatient continuity and follow-up, growing resident knowledge-base deficits, declining sense of ownership of patient outcomes, and (anecdotally) an increase rather than decrease in medical errors. This human experimentation, without any supporting preliminary data, without participant safety monitoring, and without any effort to measure and document outcomes, would never have gotten past an IRB. 

On the other hand, I applaud the IOM recommendations to spread the cost to all the payers.

Today’s residents are soft

I guess we "old-timers" were the tough docs. Why has the resident softened up?

No wonder the grades on the American medicine report card continue to drop!