What do you think about the proposed 2011 ACGME duty hour standards?
The AMA's GME e-Letter frequently asks its readers about timely topics in graduate medical education. The following comments were received in response to the question, "What do you think about the proposed 2011 ACGME duty hour standards?"
Someone is going to have to say the emperor is naked; maybe it will be the AMA.
We are failing residents and ultimately failing the public by fundamentally changing the way we educate residents in internal medicine. I have been teaching for more than 35 years and have what I think is a good perspective. When I attend on medicine or do consultations on the wards I am shocked at the level of care residents deliver.
They are just as smart as they used to be. They simply have less experience and they know less. This cannot be overcome by more didactic sessions. The strength of American medical education was our emphasis on learning by experience. More and more responsibility is shifting from residents to faculty, turning the residents into glorified clerks. When I told an intern that he could take a piece of ice and apply it to a patient's skin to see if he had cold-induced urticaria, he asked me incredulously, “Am I allowed to do that?”
They are detached from patients -- they write admission notes that regurgitate what ER or hospitalists have told them. They do not have the ability to think about cases independently. This is a disaster for the future of medicine. Their comfort and “lifestyle” are not paramount. Their education and their commitment to putting patients first is what we need to preserve.
I ask the ACGME to consider the work hours in New York state, which are stricter than the current ACGME regulations: Is care in New York any safer than care elsewhere in the nation? When the current regulations were considered for implementation, I wrote the ACGME as an experienced neonatologist who had just relocated to NYC from Philadelphia with the same request, because, after practicing in New York City, I was certain that the number of errors was no different in New York than in Pennsylvania, nor was patient safety any better in New York than in Pennsylvania. In my letter, I asked the ACGME to use evidence for its possible adoption of the then new regulations re: resident work hours. I thought excessive handoffs was not worth the added risk to patients. My request was not followed as far as I know.
Now the evidence is in. It has been proven that handoffs are associated with increased medical errors, and I know from my own practice, as well as evidence from the literature, that residents are being shortchanged in their education because:
- They do not see firsthand the results of the therapies they have implemented during the nighttime hours; and
- They are not present on rounds when the patients, their disease processes and the therapies are discussed in a physiologic framework.
I would hope the ACGME uses evidence-based not politically based reasoning to make their decision re: work hours. I agree that the newest guidelines under review far excel the Institute of Medicine's recommendations, but I believe both are detrimental to patient care and resident education. I am truly concerned about the next generation of physicians and their ability, knowledge, and stamina to treat the next generation of patients.
I read in the latest GME e-Letter that the feedback about the new duty hours has been positive. This is certainly possible, but I am not sure that I can tell what it means. It is my opinion that the new duty hour rules are arbitrary and rigid even if there is a lot to appreciate. I seriously doubt that anyone has an unalloyed love or hate for these rules but rather the reaction is likely to be much more interesting and complex than the anodyne announcement would indicate.
My principal concern is that it might be possible for hours to go away, but that is not synonymous with work going away. Residents who are in a hurry to leave in order to meet work hour rules are feeling additional stress since they are given no latitude about their work. It would be extremely useful for an organization committed to evidence and science to study rule changes and publish the results for general scrutiny. From what I have seen, there is little evidence that new work hours are safer for patients or convey the principles of medical education and practice to trainees as compared to older rules. There is some evidence that vehicular safety is enhanced in people who are not sleep deprived, but it would seem like a capricious decision to change the whole educational environment of medicine to deal with traffic safety alone.
In my previous correspondence, I offered to become involved in a dialogue with the ACGME, but nothing was forthcoming. I understand if there is not time to engage each interested party. But from the written record, it seems that very little dialogue is happening anywhere around this topic, and what comes out of the decision making process shows little sign of internal discussion or compromise. Perhaps I am not seeing the process correctly, but I would challenge the ACGME to make its decision-making process more transparent, feature conflicting views in its monographs and Web site, and explain how it is taking care to preserve the educational function of medical training. Medical education has been the prime focus of my career, and I feel that I have "lost the plot" with respect to the ever-changing requirements of the ACGME.