It’s been one year since the Accreditation Council for Graduate Medical Education’s (ACGME) most recent residency program regulations took effect, updating standards put into place in 2003. The regulations are the latest manifestation of an ongoing challenge in medical training: how to strike the right balance of optimal clinical training with patient safety, resident well-being, and other concerns.
Clearly the most controversial change in the latest regulations is the restriction of first-year residents to a work shift of no more than 16 hours and older residents to 24 hours, with an additional four hours to manage transitions in care (previously, 30-hour shifts were permitted for all residents). ACGME applied the 16-hour restriction after extensive discussions with members of an Institute of Medicine committee that drafted a report at the request of Congress that explored the dangers to patient care of sleep-deprived caregivers. The IOM report argued that revisions to medical residents’ workloads and duty-hours were necessary to better protect patients against fatigue-related errors and to ensure that residents get the best educational experience.1
This month, the ACGME begins its annual reviews of institutions to gauge the impact of the new regulations. While few expect the ACGME to find decisive answers regarding optimal work-hour regulations for residents, the 16-hour rule has both its opponents and supporters. On balance, HM appears to be well-positioned to benefit from the changes, having been given yet another opportunity to demonstrate value by helping their institutions weather the changes, enhance the residency training experience, and support the patient safety imperative.
Is 16 the Magic Number?
In defending the new rules last year, ACGME CEO Thomas J. Nasca, MD, acknowledged that the evidence linking long duty-hours and patient safety is mixed, while also explaining that another part of the rationale for limiting shifts for the youngest residents was to ease them into the profession. Older residents, he said, must be taught to recognize and manage the fatigue they will encounter regularly in their actual clinical practice, where hours are not regulated.
“It makes sense how ACGME has structured this—giving trainees the chance to learn in a more measured way, while recognizing that more experienced residents have more mature judgment,” says Daniel D. Dressler, MD, MSc, SFHM, FACP, hospital medicine associate division director for education, and associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory University School of Medicine in Atlanta. “I believe it’s an overall positive move, in terms of morale and work/life balance.”
Others disagree. Patient safety expert Lucian Leape, MD, adjunct professor at Harvard School of Public Health, decried that the ACGME rules did not apply to all residents, just those in their first year, and he rejected the assumption that one can learn to tolerate sleep deprivation.2 HM pioneer Bob Wachter, MD, MHM, professor, chief of the division of hospital medicine, and chief of the medical service at University of California San Francisco Medical Center, agrees the work-hour restrictions are here to stay—and are a good thing. At his blog Wachter’s World, he recently posted that research shows “prolonged wakefulness” degrades cognitive skills, and equates to a blood-alcohol level of 0.1, or “legally drunk in every state.”
“Even without strong evidence one way or the other, if it has improved safety, I think 16 hours is probably right for interns, and 24-plus-four hours for second-year residents and above. It’s the ACGME’s best guess, to date, of the right balance,” says Jeffrey G. Wiese, MD, SFHM, FACP, associate dean for graduate medical education, director of the internal medicine program at Tulane University School of Medicine in New Orleans, and former SHM president. “It’s no huge intellectual stretch to say that someone who’s been up for 32 hours is not in the best condition to make optimal patient-care decisions.”