A Word From The President:

It's About Time

Photo of Jordan J. Cohen, M.D.
The Washington Post ran a lengthy story* a few weeks ago calling attention yet again to the "excessive" duty hours of residents. Indeed, we have been hearing a steady drumbeat of public complaints for decades now about the risks patients allegedly run when overworked and sleep-deprived trainees participate in their care. It’s about time we took their complaints seriously. And it’s certainly about time we took our own rules seriously.

But does the public really have cause for concern about resident duty hours? Those who defend our current GME practices say no. They claim correctly that little if any hard evidence exists that patients have actually suffered at the hands of overtired residents. They also claim correctly that optimal resident education should not be held hostage to a time clock. Learning how to take care of sick people requires participation in the full course of illness and is undercut by arbitrarily assigned hours and untimely interruptions in patient care responsibilities. What’s more, the argument continues, residents are closely supervised to ensure that neither fatigue nor inexperience is a cause of harm to a patient.

Then there are those who think the answer is yes. They claim correctly that undeniable evidence exists documenting that lengthy and uninterrupted duty hours cause fatigue and that fatigue causes deterioration in high-level functioning — like that required of residents caring for sick people. They also claim correctly that optimal resident education cannot occur when house officers are too tired to absorb the lessons being taught. What’s more, their argument continues, our claim that supervision of residents provides adequate protection of patients from medical error is laughable in view of the thousands of fatal errors and near misses known to occur in our hospitals.

Here is a classic case where there is no right answer. Or, more precisely, where everyone is partially right. Resident duty hours, per se, are not a cause for public concern, but the adverse effects of sleep deprivation from too much night call surely are. Similarly, adequate supervision is the sine qua non of resident training irrespective of duty schedule, but no amount of supervision can compensate for the de-professionalizing and even dehumanizing effects of an overly burdensome duty schedule. And finally, having ample opportunity to experience illness from start to finish is critical for learning how to doctor, but so too is knowing when fatigue compromises one’s proficiency and requires transfer of responsibility to a colleague.

As with all such complex questions containing partial truths on both sides, the challenge is to find, by consensus, the balance point at which reasonable compromise can maximize the benefits sought by opposing viewpoints. Fortunately, in the case of resident duty hours, such a consensus is at hand, as articulated in the ACGME’s Institutional and Program Requirements. These requirements speak directly to the working conditions for residents and represent a well-crafted and sensible balance point between the educational need for uninterrupted involvement in the care process and the residents’ need for adequate rest to fulfill their professional responsibilities.

I should say balance "points" because all of the 27 Residency Review Committees (RRCs) have crafted standards for duty hours appropriate to their respective disciplines; six of the 27 have even specified the maximum hours per week (e.g., 80) that a resident can be involved in patient care duties. Furthermore, the ACGME’s Institutional Requirements mandate that each program sponsored by an institution "establish formal policies governing resident duty hours" and that educational goals "not be compromised by excessive reliance on residents to fulfill institutional service obligations."

So, what’s the problem? Why does the press keep beating up on us about excessive work hours of residents? The most embarrassing answer is that we don’t follow our own rules. According to the ACGME, 20 percent of sponsoring organizations undergoing institutional reviews in 1999 were cited for violations of requirements related to duty hours. In that same year, 29 percent of the orthopedic surgery programs and no fewer than 30 percent of the internal medicine, general surgery, colon and rectal surgery, and pediatric surgery programs reviewed were found in violation of the on-call standards established by their own RRCs. In only five disciplines were all reviewed programs judged to be in compliance.

Putting aside whether, as some would suggest, the RRCs’ requirements governing resident work hours are not stringent enough, our blatant disregard for our own standards is simply indefensible. Continuing to disregard them belies our fundamental professional obligation to safeguard patient welfare. Moreover, failing to fulfill our duty to regulate ourselves is an open invitation to intrusive governmental regulation and a capitulation to union organizers, whose most alluring promise to residents is protection from exploitation.

It’s about time for the academic medicine community to acknowledge the public’s understandable concerns about the potential risks to patient safety inherent in the way we train our residents. The first step on the road to reassuring the public that we are serious about protecting their interests — and to reassuring residents that the profession cares about their welfare — is to deal definitively with the widespread violations of our own rules.

Jordan J. Cohen, M.D.
AAMC President

18 May 2001