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ACGME Duty Hours Standard Spark Regulatory Debate What's in a Name? Philanthropists' Donations Giving New Names to Medical Schools Proposed New Clinical Exam Draws Cost, Efficacy Concern Leadership Q & A: A Pioneer Looks Back - And Ahead
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A Word From the PresidentResponding to a Changing World
I have a good deal of sympathy for that argument. Having trained some 40 years ago, when being on call every other night and every other weekend was routine, I was acculturated to the view that a doctor's obligation to his or her patients was boundless. All else was subordinate. Being fatigued much of the time, being often absent from routine family occasions and even special celebrations, and being unable to engage fully in non-professional interests were all part of the bargain I and my colleagues struck for the privilege of being doctors. I still feel that way. But I also feel the inexorable passage of time, and with it the undeniable and fundamental changes in medicine that several decades have wrought. Three of those changes are particularly salient to the question of limiting resident duty hours and have convinced me, and happily most others, that that question must be answered affirmatively. The first is the pace and acuity of hospital care. Forty years ago, a patient with an uncomplicated MI was hospitalized for three weeks! After the initial workup, the rest of the care was largely a matter of brief bedside chats on rounds. Nowadays, such a patient, if admitted at all, might be discharged in three days, quickly freeing his or her bed for a much sicker patient. The length of stay has been shortened just as dramatically for virtually all categories of patients, while the acuity threshold for hospital admission has risen. These changes have naturally increased the level of residents' stress and transformed their learning environments from contemplative to hebephrenic. The second salient change is the exponential growth of hospital technology and the accompanying demands for vigilance and mastery that fall heavily on physicians-in-training. In the days before respirators, dialysis machines, pacemakers, transplants, chemotherapy protocols, ICUs, CCUs, SICUs, and NICUs, a resident's life was downright serene by comparison to today's technological maelstrom. The third, and perhaps most significant change, is "generational." Today's residents are not products of the '50s. They demand and deserve a different "lifestyle" than previous generations sought. Many more are married and wish to stay that way. Many more are women with child care responsibilities. And many, thankfully, have interests outside of medicine that require time to pursue. An additional rationale for limiting resident duty hours is the convincing experimental evidence from sleep researchers documenting the deterioration of high-level mental function that accompanies sleep deprivation and accumulated sleep debt. Although I know of no hard evidence linking resident fatigue with substandard or unsafe care, who would argue that the grueling duty schedules required in some training programs are without risk to patients? Certainly the public, through the news media and their representatives in Congress, has concluded that excessive duty hours do pose such a risk, and they are calling for a response, either from us as a profession or from government, if necessary. Fortunately, the profession is responding. The AAMC, for its part, has been on record for the greater part of the past two decades advocating limitations on residents' duty hours. Our updated guidance on the matter was circulated last fall.1 The Accreditation Council on Graduate Medical Education (ACGME), no doubt spurred by pending federal legislation, has recently proposed new standards, slated to take effect July 2003. Although not as stringent as those put forth by the AAMC, these new standards should go a long way toward restoring a better balance between the need to inculcate the ethic of professional responsibility for continuity of care and the need to ensure that residents retain the mental acumen both to provide safe, high-quality patient care and to be attentive learners. But adopting new standards on paper, while a necessary step, is far from sufficient. The hard part is yet to come - restructuring those training programs that are not yet in compliance. As difficult as that may be, I have no doubt that the creativity exists in our community to find ways to sustain high-quality graduate medical education within a still generous, albeit limited, time allotment. To assist with this restructuring process, the AAMC intends to showcase model programs that have successfully met their residents' educational needs without requiring excessive duty hours and without compromising patient care in the process. We have clear evidence that the public is concerned about this issue, and legitimately so. We have an opportunity to address their concerns by demonstrating our profession's willingness and ability to regulate itself. That means everyone must voluntarily comply with the ACGME's new requirements for resident duty hours. If we miss this opportunity to implement reforms, I doubt we'll have another. Legislation is already pending in both houses of Congress that would gladly impose "one-size-fits-all" governmental regulations if we fail in our efforts to discipline ourselves.
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Contact Us © 1995-2008 AAMC Terms and Conditions Privacy Statement |
Few issues facing our community over the past couple of decades
have been as contentious as whether or not to place upper limits
on resident duty hours and on-call schedules. Many educators have
resisted the call for such limits, arguing that the ethic of the
medical profession and the need to ensure continuity of care run
counter to setting time limits for patient care responsibilities.