ACP: Resident work hours – Managing a precarious balance

The following is part of a series of original guest columns by the American College of Physicians.

by Steven Weinberger, MD, FACP

In December 2008 the Institute of Medicine (IOM) released its report entitled “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety,” in which it proposed a number of changes to the current regulations developed and enforced by the Accreditation Council for Graduate Medical Education (ACGME).

Since the time of the report’s release, medical educators and the ACGME have been weighing the issues and the opinions expressed by the IOM as well as by countless individuals and groups that have a stake in patient care or in the training of tomorrow’s physicians. I do not envy those leaders at the ACGME who are currently working hard to translate all this information into a new set of regulations, as they try to apply Solomonic wisdom in balancing a variety of issues that are hardly black and white.

Before considering these issues, it may be helpful to lay out three major goals and principles that should drive this process and for which there seems to be reasonable consensus:

1. Guaranteeing that patients receive safe, high quality care.

2. Assuring that residents receive an optimal education and training experience.

3. Maintaining a training environment for residents that is humane and capable of balancing goals #1 and 2.

Within this framework, however, each issue seems to have its pluses and minuses.

* Restrictions on consecutive and total hours worked allow residents to be better rested, but hand-offs in responsibility mean less continuity of patient care during an acute illness.

* Better rested physicians may have greater ability to learn and better knowledge retention, but may be deprived of the experience that comes from following patients continuously through the course of an illness.

* Mandating specific work hours can assure that residents have a more humane life during training, but may compromise residents’ autonomy in deciding what is best for their education and training, or what is best for their patients.

* Care provided by the well-rested resident may be safer for the patient today, but may be less safe and of lower quality for future patients if the resident’s training and experience are compromised.

* Residents may be better rested with restricted hours, but faculty physicians, who may need to “pick up the slack,” are not working under similar restrictions.

So what is the solution? Although I certainly do not have the answers, I do have several suggestions, many of which have been raised by others who also have a stake in this game.

* A uniform policy that is inflexible, based on process rather than outcomes, and that applies to all residents in all specialties and in all training programs, is likely to fail.

* Creativity in scheduling should be encouraged, allowing better matching of resident coverage and patient care/service needs than has traditionally been done.

* At a systems level, schedules for providing care should be designed collaboratively by residents working with training program leadership, to assure that the interests of residents, patients, and quality of care and training are all well represented.

* At an individual level, residents and the individuals with whom they work – colleagues, supervising faculty, nurses, and patients – must all be given the freedom and the responsibility, without any fear of punitive action, to express and act on concerns that a resident is too fatigued to provide care. Honesty about this issue to oneself and to others should become part of the culture of training as an important component of professionalism, and taking a nap should not be considered “a sign of weakness” or poor performance.

* Systems of care must be sufficiently team-based to provide necessary supervision and to allow, when needed, for cross-coverage by other residents, supervising physicians, or other healthcare personnel.

Although it would be difficult at this time to develop a system on a large scale that accommodates all the above principles, development of some pilot programs with careful assessment of outcomes might provide models that could be applied more broadly, in a fashion that would best meet the needs of patients and residents, both today and in the future.

Steven Weinberger is Deputy Executive Vice President and Senior Vice President, Medical Education and Publishing, of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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