To the Editor:
In July 2011, the Accreditation Council for Graduate Medical Education implemented stricter regulations for resident duty hours. The hope was that mitigating fatigue and increasing supervision would improve the safety and quality of patient care as well as the education of residents.1
Prior to this year, 30-hour call shifts were the norm for many residents in our hospital and nationally. The rigor of these shifts taught us to maintain professionalism and compassion amidst life-and-death stakes. Overnight calls, despite the unavoidable fatigue, were training grounds for independent decision making and some of the most exhilarating times of residency. These shifts were often the best opportunities to watch the evolution of disease away from the pages of a textbook and to experience the transition from trainee to doctor under appropriate supervision. Most important, the extended hospital shifts were the time for residents and patients to bond—developing the critical doctor–patient relationship and designing a collaborative plan of care.
No amount of shift-design or fatigue-mitigation strategies can replace such important experiences—from a medical and humanistic standpoint. The decrease in daily continuity has whittled away the interactions on which the patient–doctor relationship depends. Electronic cross-cover lists have replaced personal interactions as residents’ primary source of information. On the whole, the changes have established a norm of perpetual patient transfers from one team to the next, with diminished opportunities for any one team to develop responsibility for a patient. As a result, we residents are losing “our” patients.
However, the new regulations are not without justification. They were implemented in response to reasonable public concerns2 and strong recommendations by the Institute of Medicine.3 From the outside, and even in the trenches, the former work conditions sometimes seemed inhumane. Yet a large, multispecialty survey of residents vocalized concerns that regulation paradoxically worsens residents’ quality of life and education and decreases patient safety.4 Therefore, the primary goals for these changes have not necessarily been borne out in practice.
Residency is merely a small portion of our careers, but it provides the sole opportunity to learn medicine with safe and supervised increases in autonomy. The design of these years should allow residents to develop time and stress management skills. The new regulations disenfranchise residents. To marginalize and fractionate residents’ involvement in patient care and education may do more harm than good to the residency experience, patient care, and potentially to the entire health care system. We and our fellow residents will be less prepared to meet the demands of an attending physician schedule if training does not allow some degree of rigor while we still have the safety net of experienced faculty. We fear that our current cohort of trainees may come to be known as “the generation who stopped spending nights in the hospital.”
Brian C. Drolet, MD
Resident, Departments of Plastic Surgery and General Surgery, Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island; [email protected]
Kenneth D. Bishop, MD, PhD
Chief resident, Department of Internal Medicine, Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island.
1. Nasca TJ, Day SH, Amis ES. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363:1679–1680
2. Blum AB, Raiszadeh F, Shea S, et al. US public opinion regarding proposed limits on resident physician work hours. BMC Med. 2010;8:33
3. Iglehart JK. Revisiting duty-hour limits—IOM recommendations for patient safety and resident education. N Engl J Med. 2008;359:2633–2635
4. Drolet B, Spalluto L, Fischer S. Residents’ perspectives on ACGME regulation of supervision and duty hours—A national survey. N Engl J Med. 2010;363:1–5