Whitcomb, Michael E. MD
This issue of the journal contains a great deal of information that should be useful to those responsible for graduate medical education (GME) programs. It is a sign of the times that I have chosen to limit my comments to those articles and research reports that discuss the duty-hours limits established by the Accreditation Council for Graduate Medical Education (ACGME). I am ambivalent about focusing on this issue, since in my January editorial I argued that it was time for those responsible for GME programs to shift the focus of their attention from the duty-hours limits to an examination of the overall quality of GME. But recent events have prompted me to return to the topic once again.
In November 2003, the journal published a research report documenting that while it was not uncommon for residents, regardless of specialty, to work more than an 80-hour week, the work week of general surgery residents (and residents in other surgical disciplines) far exceeded the average work-week of residents in all other specialties.1 Those findings confirmed what many involved in the duty-hours debate already knew—that those responsible for general surgery residency programs would have the greatest difficulty complying with the sort of duty-hours limits that have now been mandated by the ACGME. It is not surprising, therefore, that a formal request to allow surgical chief residents to work an 88-hour week—a waiver of the 80-hour limit allowed for by the duty-hours policy adopted by the ACGME—was presented during the ACGME meeting held this past February. Although no action was taken then, it seems likely that the council will act this June.
The particular challenge that the academic surgical community faces as it grapples with the duty-hours limits is reflected in three personal essays published this month. Josef Fischer, a distinguished surgical educator, argues strongly that the imposition of the duty-hours limits runs counter to the commitment that surgeons have to provide continuity of care to their patients. And he notes that the limits most heavily affect senior surgical residents, largely because they have the greatest responsibility for the care of surgical patients in institutions that conduct surgical training programs. This, of course, explains the request made at the February ACGME meeting that the 80-hour limit be waived for them. He goes on to argue that the arbitrary nature of the 80-hour limit also may have dire consequences for medicine in general.
The essays by Romanchuk and by Barone and Ivy provide different perspectives. For the most part, they do not view the issue with the same degree of concern as expressed by Fischer. Romanchuk comments on the experience in Canada, where duty-hours limits roughly comparable to the ACGME's have been in place for over a decade. His comments are important because the current discussion in this country almost certainly mirrors the discussions that occurred when duty-hours limits were adopted in Canada. In their essay, Barone and Ivy present contrasting views on the issue. They suggest that their differences, like those voiced in the surgical community at large, reflect differences in their ages. No doubt the variety of views expressed in the three essays will be heard over and over during the next few years.
I doubt that the ACGME will allow any wholesale changes in the duty-hours limits in response to requests that the limits be waived, even though the policy that was adopted allows for that. My reason for believing this is quite simple—there is a growing body of evidence showing that residents, even those who work less than an 80-hour week, often suffer from both acute and chronic sleep deprivation, and that those states adversely affect their personal lives and their ability to perform their work. Two research reports appearing this month (by Rosen et al. and Papp et al.) add to that body of literature. Even though I appreciate the thoughtful comments of Fischer and other surgical educators who share his views, their concerns about the impact of the limits on continuity of care and, therefore, on the quality of care provided to patients are unlikely to override the public's concerns that sleep-deprived trainees are allowed to give that care.
I concur with those concerns and believe that there must be some limits on residents’ duty hours. Even those who think that the present limits will disrupt continuity of care have never claimed that residents should be on duty without stop for weeks on end, which means that continuity of care must be disrupted at some point to give those residents a break. If so, then what makes an 80-hour limit more dangerous for patients than a 90- or 100-hour limit, particularly when one must factor into the risk-benefit equation how greater sleep deprivation contributes to the relative risk involved?
What needs to be done, of course, is for researchers in the field to study, on a specialty-specific basis, the degree to which handoffs—passing responsibility for the care of specific patients to another resident—really impose risks on patient care and what factors are responsible for the risks that are identified. Armed with that information, I believe it would be possible to design systems of care that would minimize any apparent risk. Given the reality that handoffs have to occur at some point in time, it seems to me that it is more reasonable to approach the issue at hand in this way, rather than simply by extending the duty-hours limits for some residents.
One of the interesting things about this emotionally charged issue is how little things seem to change over time. The differences of opinion in the surgical community reflected in the piece by Barone and Ivy are not new. Here is how one young surgical educator, a member of the faculty at Vanderbilt at the time, viewed the issue two decades ago:
Both Massachusetts and New York have proposals on the books that would put a limit of eighty hours on the number of hours a week a resident could work. That would be a marked improvement. I think residents should be allowed one day a week away from the hospital, but few program directors are likely to let this happen. In addition, residents should be on call no more than every third night and clearly should be given some opportunity to rest after a twenty-four hour stint.2
I suspect that Senator William Frist, the author of the statement, is pleased that the ACGME has finally adopted duty-hour limits.
Back to that plea I made in January 2003. Even though not everyone agrees with the ACGME's position, the fact is that duty-hours limits are now in place and programs in all specialties must comply if they wish to remain accredited. Given this, the challenge the academic community faces is to figure out how to provide residents with the best possible education within the constraints the limits impose on program design. And many programs are doing exactly that. I have been quite impressed as I have traveled about to see some of the innovative ways that programs are accommodating to the limits—indeed using them to improve the quality of their programs. I suspect we will be publishing in the near future articles describing how this has been accomplished in different disciplines. Stay tuned!
1.Baldwin DC, Daugherty SR, Tsai R, Scotti MJ. A national survey of residents self-reported work hours: Thinking beyond specialty. Acad Med. 2003;78:1154–63.
2.Frist WH. Transplant. A Heart Surgeon's Account of the Life-and-Death Dramas of the New Medicine. New York: The Atlantic Monthly Press, 1989.