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COMMENTARY |
Department of Pediatrics, Children’s Hospital, University of Colorado Health Sciences Center, Denver, CO 80218
Few topics in graduate medical education have provoked as much comment and controversy as the recent decision of the Accreditation Council for Graduate Medical Education to limit resident "duty hours," defined as all clinical and academic activities related to the residency program. Regulations that went into effect July 1, 2003, limit duty hours to 80 hours per week, averaged over a 4-week period. In addition, residents may spend no more than 24 consecutive hours on duty, although they may remain on duty for up to 6 additional hours, for a total of 30 hours, to participate in didactic activities, transfer care of patients, conduct continuity clinics, and maintain continuity of inpatient medical care. No new patients, defined as any pa-tient for whom the resident has not provided care during the previous 24-hour period (except for patients who are part of the resident’s continuity panel or the panel of the resident’s continuity team), may be accepted after 24 hours of continuous duty.1
One might ask: "Why the fuss in pediatrics?" Many pediatric training programs have been close to 80 hours per week for some time. The requirement that housestaff take on new patients for no more than 24 hours and be on duty for no more than 30 hours is more of a challenge, especially for intensive care and the busiest inpatient rotations, but this represents only a minority of trainees at any one time. Nevertheless, debates about the advisability of limiting work hours continue.
The case for limiting work hours is compelling. Scientific data and common sense support the importance of state of alertness for doing the best job. At some point, fatigue impairs cognitive abilities and judgment.2–4 The precedents of professions such as airline pilot or long-distance truck driving are cited. Safety concerns have limited hours in those professions and others, the argument goes; why not with medical residents? Yet the proposition that cognitive abilities and patient safety are compromised by resident fatigue has been difficult to prove.2–7 Studies have not been of the best design or of sufficient statistical power to demonstrate differences in rare adverse events.
One author reasoned that, in any case, adverse events are not the appropriate end point.7 He observed that, although fatigue may or may not endanger patients, there is little doubt that it leads to impatience and irritability. A tired, irritable resident is not the best person to manage or learn from the complicated physician-patient interactions that arise in contemporary clinical care. Patience and capacity for empathy are likely to be in short supply.
Objections to limiting work hours have centered on concerns that continuity of care will suffer and that a professional sense of ongoing responsibility to patients will be replaced gradually by a fragmented, shift-work approach.8 Neither these possibilities nor ways to mitigate them have been studied systematically.
The greater problem with limiting resident work hours is that limitation of work hours represents an oversimplified approach to a complex problem.9 With regard to patient safety, proper supervision is at least as important as alertness. However, the real challenge ("the monster under the bed") is that graduate medical education needs to be rethought from top to bottom.
The goal of graduate medical education is to produce competent, appropriately self-confident physicians. Education needs to occur in an environment that enhances rather than compromises patient safety. The task is daunting. The volume of information a resident must master is increasing exponentially, yet the duration of training in pediatrics remains constant at 33 months. That is not to say that a simple increase in the duration of training is likely to guarantee a broadly competent pediatrician any more than a simple decrease in work hours is to guarantee patient safety.
The monster under the bed is the intimidating need for a comprehensive rethinking of how graduate medical education should be done. Our quasi-apprentice approach no longer suffices. Even a work week far longer than 80 hours would be insufficient to "learn by doing." There is too much to learn and do. The situation is exacerbated by the considerable inefficiency of a resident’s workday (and night).10 Fortunately, technology soon may reduce the time spent tracking down (or, worse, working around a lack of) patient information.11
The challenge for us in pediatrics is not different than that for all graduate, and for that matter undergraduate, medical education. The old model of "see one, do one, teach one" is unacceptable and ineffective. The polar alternative of a supervisor monitoring every move and interaction is equally unsatisfactory. We know that retention from didactic lectures is poor. Yet most of us continue to lecture residents; residents, perhaps out of habit or for lack of alternatives, continue to request lectures. The situation is analogous to the anecdote of the man who drops his key in the dark yet continues to look under the street lamp because that is the only place he can see.
Opportunities for research are enormous. Do we introduce minicourses on a variety of basic topics (eg, fluids and electrolytes) into residency programs? Should we include an assessment of competence? If so, how should that be done? How do we teach housestaff to deal with chronic illnesses and behavioral problems in an environment in which longitudinal knowledge of family dynamics is nearly impossible? Should we use simulated patients? The honest answer to these questions and a long list of others is that we don’t know. We need to find out.
First, we need more pediatricians and other medical educators trained to ask and answer such questions. Second, we need a source of funds to support their studies. Marginally fewer hours with which to work is only a small aspect of a large challenge.
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FOOTNOTES |
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Reprint requests to (M.D.J.) Children’s Hospital, B065, 1056 E 19th Ave, Denver, CO 80218. E-mail: jones.doug{at}tchden.org
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