Are We Training Physicians to Be Shift Workers?

During residency training, young doctors learn the requisite skills, knowledge, and values essential to the practice of medicine. We will all agree that to learn, the resident must have the desire and drive to master the essential knowledge and skills of his or her specialty. Furthermore, we would agree that the residency must create an environment that fosters learning and professional responsibility.

To accomplish these demands, residents must be adequately supervised and they must be given increasing patient care responsibility as their knowledge and skills grow. They must also have adequate rest so that fatigue does not interfere with their learning and patient care.

The model in which young doctors acquired their medical skills by working unsupervised on poor patients at county hospitals is, fortunately, a thing of the past. And the days in which residents were on call every other night or every third night without any days off in a given month are now also history.

But as we have worked to correct old abuses, might we be creating new problems? The Accreditation Council for Graduate Medical Education (ACGME) has promulgated a comprehensive set of new rules to govern residency education.¹ Those rules prescribe standards for resident supervision and the number of hours that residents may work. To correct a number of serious past abuses, have we created a new standard that in the long term will interfere with resident learning and his incorporation of professional standards? By developing prescriptive standards to be applied to all residencies, have we interfered with the unique learning opportunities that exist in each one? I believe the answer is yes to these 3 questions.

Here I will address the new duty hour rules. In the Western World since the time of Hippocrates, being a physician meant holding a special standing in society, and it meant special responsibilities for the practitioner and his teachers. The new ACGME duty hour standards prescribe in essentially all circumstances, how many hours a resident may work (Box). They require that when a resident must work extra hours, he must report this fact to the training director.

This reporting requirement effectively abrogates the historic values transmitted to each physician in the Hippocratic Oath. Staying with one’s patient until the patient is stable is a core element of being a physician. The need to justify or document why one stayed with a sick patient after “regular duty hours” is tantamount to an employee writing to his supervisor to justify overtime pay when he must remain at work in an emergency after a shift change.

Integral to being a resident is the acquisition of skills and knowledge of a physician. But another equal part is experiencing the impact on one’s self of caring for another in life-or-death circumstances or of engaging the families of the seriously ill. In such situations, a focus on hours worked or duty hour rules has no place. The need to document why one needed to stay with a sick patient would seem absurd to some.

Compare the first year of residency to the first year of parenthood. If a new mother spent over 16 hours caring for her child on a given day, would we ask her to document or justify why she needed to spend the extra time?

The new parent and the new resident both experience the demands and obligations-as well as the pleasure-of caring for another. Unique experiences transcend our usual feelings of fatigue or focus on schedule. It is not an unusual circumstance that necessitates that a resident remain after his usual duty hours are completed. Rather, the realities of health care and illness and the resident’s sense of responsibility and essential engagement dictate that need. The needs of patients and their families or the needs of a child in the middle of the night will-and must-dictate the actions of residents, not the number of hours they work or ACGME requirements.

If the ACGME is concerned that residents will or may be misused by their program, the ACGME should say so. It can then clarify the mechanisms that residents can use to obtain redress for their concerns without fear of retaliation by the residency. The ACGME must not interfere with the resident’s evolving sense of responsibility and identity as a physician. What we need to ensure patient care and resident learning are enforceable guidelines that grant appropriate authority to each residency program.

Physicians must not just become shift workers. Staying on after one’s usual duty time must not be equated with justifying overtime pay.

Maximum Duty Period Length: New Standards From the Acgme^aDuty periods of PGY-1 residents must not exceed 16 hours in duration.

In unusual circumstances, residents on their own initiative may remain beyond their scheduled period of duty to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required continuity for severely ill or unstable patients

Under those circumstances, the resident must:

Appropriately hand over the care of all other patients to the team responsible for their continuing care; and, Document the reasons for remaining to care for the patient in question and submit that documentation in every circumstance to the program director. The program director must review each submission of additional service, and track individual resident and program-wide episodes of additional duty.

^a ACGME Common Program Requirements (page 17) http://acgme-2010standards.org/pdf/Common_Program_Requirements_07012011.pdf. Accessed October 7, 2010.

References:

Reference

1. ACGME Approved Standards. http://acgme-2010standards.org. Accessed October 7, 2010.