The Accreditation Council for Graduate Medical Education (ACGME) has instituted new limitations on internal medicine intern and resident duty hours, effective July 1, 2011. Among other requirements, the new standards
include rules that duty periods of post-graduate year (PGY)-1 residents must not exceed 16 hours in duration and residents must not be scheduled for more than six consecutive nights of night float.
Training program directors Robert A. Wolff, MD, of M. D. Anderson Cancer Center, and Thomas H. Davis, MD, of Dartmouth Hitchcock Medical Center, shared their perspectives on the new ACGME regulations with ASCO Connection. Both serve as members of the ASCO Professional Development Committee.
“Residents...Need to Practice Seeing Patients”
Robert A. Wolff, MD
My residency experience didn’t have anything to do with 80 hours. I trained at Duke and most of my clinical rotations as an intern and a junior resident were every third night on call at the hospital, no time off the next day, and an occasional weekend day off. That’s a far cry from what we have today.
I’m observing two issues here. The first is that while changes in the duty hours are primarily focused on internal medicine residents and not directly mandated for hematology/oncology fellows, they are having an impact on the fellows. At our institution, we have partnerships with and help run the hematology and oncology consult services at LBJ County Hospital and at the University of Texas Health Science Center in Houston. Because the residents are less available to help run those services, more of the day-in/day-out work of direct patient care, particularly on the weekends, is going to fall on the shoulders of the fellows. Instead of transitioning into a supervisory/teaching mode, they’re feeling as if they’re going backward in terms of their trajectory in their own training. This is counterproductive—being able to teach someone is a valuable part of learning the discipline yourself.
The other thing we’re seeing, at least as our sponsoring institution has currently designed the rotations, is that there’s fragmentation of continuity of care among residents. They’re off again and on again, so they’re not seeing the course of the acute problem of a hospitalized patient, and we definitely think that’s having an effect on the residents’ training.
The duty hours are not preparing residents or hematology/oncology fellows for a career in subspecialty medicine. They simply are not getting sufficient experience. We call it “the practice of medicine”—trainees need to practice seeing patients in the outpatient setting, the inpatient setting, in the middle of the night, during the day.
Supervision built into the system
For as much as data have shown that when you’re not rested you’re apt to make mistakes, there’s a lot of supervision built into the system. Responsible residents, if they’re unsure, will seek help from more senior, more experienced people in the hospital. If a resident makes an order that the nurses are uncomfortable with, the nurses will go up the chain of command and question that order—same with the pharmacists. There is a fellow on call in the ICU that residents can turn to for assistance in patient management. Patient safety is a legitimate concern and I’m not trying to dismiss it, but medicine is not practiced in a vacuum anymore. Most academic centers have tried to create a culture in which people can call for help when they’re uncertain about the best care for the patient.
What I would like to see is a clearly defined and realistic escalation in duty hours and time off over the course of training. If interns can only do 16 hours at a time, then junior residents should be expected to do more than that and have less time off post-call, and senior residents can be expected to work harder and have even less time off, and the same is true of fellows. There’s not going to be a return to the old work-until-you-drop attitude because it’s not going to attract fellows to your program in a competitive marketplace. But by the same token, residents and fellows need to have a sense of ownership, and to learn for themselves what their limitations are and how much they need to seek help when they’re tired.
“Too Many Patient Safety Eggs in the Resident Fatigue Basket”
Thomas H. Davis, MD
I finished medical school in 1986 and did my internship, residency, and fellowship before there were any duty hours regulations. When I was an intern it was much easier to count the number of hours in a week that I was not at work (which I could often do on the fingers of two hands) than to count the number of hours that I was at work.
The terms “intern” and “resident” were deliberately chosen in the early part of the 20th century because you really lived in the hospital. The experience was purposefully designed to be like boot camp in the army: an immersion experience to strip away your old identity and be reborn as a physician. It set you apart, it made your life different, it changed you forever.
You can argue if that was healthy for the individual and his or her family, and in many ways it may not have been, but in terms of getting physicians who were dedicated and had a very high level of professional standards, I think it did quite well for 100 years. Having said that, I’m still very impressed with how professional, dedicated, and selfless the current generation of trainees seems to be. It may not be necessary to have that kind of conversion experience. But we need to find ways to augment the professional attachment of the young physicians to their profession, their patients, and their calling.
My impression is that residents coming out under the current duty hour limitations aren’t quite as experienced—they just haven’t spent as much time with as many patients. They’re a little greener. They still know a lot but they haven’t seen as much. For example, I worked with an intern in March, late in the academic year, and this was the first time he had performed a lumbar puncture. By the time I was a March intern, I had probably done half a dozen. On the other hand, I don’t see residents falling asleep in conferences the way I did, so they’re definitely better rested and a little less beaten up by medicine. There are plusses to the system.
A number of patient-safety factors
Overall, though, I think that we have put too many patient safety eggs in the resident fatigue basket. It is good to have less-tired interns and residents taking care of patients, but there are many other factors that impair patient safety. One is the unintended consequence of the duty hours restrictions: more handoffs, sign-outs, and sign-ins. There is an irreplaceable familiarity with a case that you get when you see a patient over a long period of time that just doesn’t translate to a sign-out list—you catch things in the patient’s clinic course that you don’t catch if you’re just cross-covering. The handoffs generate patient-safety issues of their own.
There are also so many more distractions in hospital medicine today. Our residents may be better rested, but they’re doing more multitasking which gets in the way of good patient care. The documentation that is required by a lot of agencies gets in the way. emphasis on quick discharge gets in the way. Attention to the patient is hijacked by attention to the chart.
I would prefer to see the ACGME focus on the real endpoint, impaired performance, rather than simply the numerical duty hours. We’re spending a lot of energy and time counting hours when we should be able to come up with biometric or psychometric measures of fitness for duty and use those as an endpoint.
Dr. Wolff, a gastrointestinal cancers specialist, is the Director of Educational Programs in the Division of Cancer Medicine at M. D. Anderson Cancer Center. He has served on the ASCO Cancer Education Committee.
Dr. Davis is the Director of the Hematology/Oncology Fellowship Program at Dartmouth Hitchcock Medical Center and specializes in head and neck malignancies. He served as 2010-2011 Chair of the ASCO Oncology Training Programs Subcommittee.