To the Editor:
In 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted duty hours standards that limited residents and fellows to 80 hours of work per week. It is possible that the 10-fold increase between 1998–1999 and 2008–2009 in the number of graduate medical education programs using at-home call only (via telephone and/or other electronic means, including responding to e-mail and reading films) may be one unintended consequence of this action. In 1998–1999, 190 programs (2.4%) had only a home call schedule and no hospital call versus 2,269 programs (25.8%) by 2008–2009, based on data collected by the American Medical Association and the Association of American Medical Colleges.
These changes have been accepted or found beneficial by trainees in certain specialties and subspecialties (imaging, for example); for others, increased at-home call may be seen as “an abuse of the 80-hour work week.”1 Nonetheless,
with increasing acceptance of and advances in communications technologies in medicine (and society at large), the lines between “work” and “home” continue to blur. Just as the practice of telemedicine continues to grow, a “virtual presence” in one's residency/fellowship program may become more common, particularly in certain disciplines that lend themselves to technological interventions… . From an educational perspective, at-home call replacing in-house call decreases the opportunities for senior resident physicians to interact directly with junior resident physicians at the bedside… . Further, overuse of at-home call jeopardizes the irreplaceable opportunities for face-to-face, in-person exchanges—with colleagues, mentors, and patients alike—that are a key component of medical education and training as well as the inculcation of professionalism.1
From a patient safety perspective, more use of at-home call may increase the possibility of miscommunication on clinical issues. Also, the demands of training require that residents have protected time for rest and relaxation, free from work-related interruptions. Residents must have “downtime,” as research on sleep deprivation and burnout clearly shows.
The December 2008 report on duty hours of the Institute of Medicine2 did not address this issue. More research and data on at-home call and its effects are needed, from both programs and residents; the ACGME could facilitate this through its current data collection processes and annually release aggregate data by specialty. Based on those and other data, a change to current duty hours requirements may be in order to account for all hours worked, whether in-hospital or at-home, while allowing for flexible solutions from one specialty to the next.
Fred Donini-Lenhoff, MA
Director, Department of Medical Education Products, American Medical Association, Chicago, Illinois; email@example.com.
Sarah E. Brotherton, PhD
Director, Department of Data Acquisition Services, American Medical Association, Chicago, Illinois.
Paul H. Rockey, MD, MPH
Director, Division of Graduate Medical Education, American Medical Association, Chicago, Illinois.
1 Dalton CE; AMA Council on Medical Education. Report 5: Use of at-home call by residency programs. In: Reports of the Council on Medical Education. American Medical Association Council on Medical Education Report 5-I-08. Available at: http://www.ama-assn.org/ama1/pub/upload/mm/38/i08cmereports.pdf
. Accessed January 2, 2010.
2 Ulmer C, Miller Wolman D, Johns MME, eds; Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington, DC: National Academies Press; 2009. Available at: http://books.nap.edu/openbook.php?record_id=12508
. Accessed January 22, 2010.