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A Word from the President: Will We Be Fit for Duty?

AAMC President and CEO, Darrell G. Kirch, M.D.When I was a resident at what was then Denver General Hospital, I remember being so tired that the only thing I knew for certain was that I had reached a state of fatigue in which my thinking was no longer clear. As a point of pride, I recall trying mightily to “self-monitor”—that is, focus on avoiding making certain decisions unilaterally because I didn’t have the clarity, and therefore, the confidence to make them. I also felt caught in the trap that I am certain others of my generation experienced: that the sign of a “good” resident was never to acknowledge anything less than complete mastery of the situation. Today, remembering that experience, I wonder how I would feel about someone as foggy as I was treating a member of my family.

When considered from this perspective, the persistent concern underlying our discussions about duty-hour standards becomes clearer. It is not a matter of whether we need standards, but how these standards should be developed and implemented. These discussions, stimulated in part by the 2008 Institute of Medicine (IOM) report Resident Duty Hours: Enhancing Sleep, Supervision, and Safety, and more recently by new standards by an Accreditation Council for Graduate Medical Education (ACGME) task force, have led many to conclude that the “how” is intrinsically linked to our learning environments. (In fact, ACGME CEO Thomas Nasca, M.D., in referring to the proposed guidelines in last month’s Reporter Viewpoint, called them “learning-environment standards.”)

As we prepare to work with the ACGME during implementation of the standards, four factors regarding these learning environments will be key:

Engaging residents as partners. As new doctors who simultaneously learn from faculty and mentor their more junior colleagues, residents play a unique role in culture change. For example, many institutions are finding that residents—if engaged early on as part of the patient safety process—can serve as critically important change agents, especially if they are empowered to acknowledge when they are impaired by fatigue.

At the same time, we must continue to recognize that residents are learners first. This is the fundamental principle underlying the AAMC 2006 Compact Between Resident Physicians and Their Teachers. Endorsed by more than 30 professional medical societies and organizations, including the ACGME, the compact was developed to guide GME sponsors, program directors, and residents in fostering open communication. Whether managing resident fatigue or ensuring safe transitions in care, the compact’s tenets are vital to better dialogue among caregivers and improved transfer of patient information.

Fortifying the evidence base. Co-chaired by representatives from two AAMC member institutions, the ACGME task force worked diligently and thoughtfully to draw upon available research on sleep issues and patient safety. In addition to commissioning three independent literature reviews, the task force conducted a Web-based survey of designated institutional officials, program directors, faculty members, and residents. Further, it solicited position statements from more than 110 medical organizations and heard testimony from as many experts (including several from the IOM report committee). Their work is an important start, but more research is needed to address a host of open questions. For example, what is the real impact of limiting the duty schedule for first-year residents’ on their well-being, learning, and, most important, patient safety? Does sleep physiology research and the influence of fatigue on performance offer guidance toward better assessment of “fitness for duty”? Academic medicine must be ready to help develop a research agenda and advocate for studies that will address these, and other, questions.

Focusing on flexibility. By paying particular attention to factors such as time on duty, resident supervision, and appropriate workloads for first-year residents, the ACGME has laid an important foundation for getting us out of “clock-punching” mode. Additionally, the task force is to be commended for the flexibility it provides with standards that accommodate differences in patient care delivery and educational needs among specialties.

However, we must acknowledge that many institutions, particularly safety net hospitals, are not prepared to support the infrastructure needed to meet new standards, especially given the short time line for implementation (less than a year). Even as we commend the ACGME for flexibility in the standards, we recognize that monitoring and oversight will be more challenging and resource-intensive. Additionally, most institutions lack sufficient numbers of health professionals needed for a balanced work force to care for patients in teaching settings. We will need to address these challenges.

In contrast to the situations I encountered as a resident, I often hear residency directors and others make passionate arguments that the pendulum has swung so far in the direction of limiting duty hours that we have lost some core elements of training, especially regarding learning from the course of an episode of illness. Our primary challenge remains in maintaining the balance between ensuring patient safety and providing learning opportunities.

Continuing the discussion. Our 2010 annual meeting provides several venues for dialogue with the ACGME, our member institutions, and stakeholders about the new standards. In addition to a Sunday focus session featuring Dr. Nasca, the Group on Resident Affairs is sponsoring two plenary sessions on Tuesday—one about preparing for the ACGME standards, and the other on tools and methods for monitoring compliance.

Clearly, pushing human beings past the limits of good performance is never wise, especially when lives are at stake. Going forward, we must strive to create learning environments in which residents can acknowledge their need for rest, supervisors can better gauge how residents are faring, and institutions are able to make needed structural changes. The AAMC and its members stand ready to work with the ACGME to ensure that anyone delivering clinical care is “fit for duty.”

Darrell G. Kirch, M.D.
AAMC President and CEO