Belt Tightening


Let the debate formally begin.

Proposed regulations (PDF) from the Accreditation Council for Graduate Medical Education (ACGME) that limit first-year residents to 16 hours of duty will be seen either as an awakening or an abomination to educational leaders, according to the incoming president of the Association of Program Directors in Internal Medicine (APDIM).

“The draft ... will be welcomed by programs wishing to manage fatigue and will be seen as a threat by programs who have not yet accepted the need to reform graduate medical education,” says Ethan Fried, who takes over as APDIM president July 1.

The new changes come as no shock to academic hospitalists who have been waiting for the prescribed five-year update to the landmark 2003 duty-hour standards, especially after the recommendations published in the Institute of Medicine’s 2008 report “Resident Duty Hours: Enhancing Sleep, Supervision and Safety.” If approved, the new regulations will likely take effect in July 2011.

The data points of the rules will be debated thoroughly between now and then, but Dr. Fried views the recommendations as more than just tweaks to the existing infrastructure governing residency programs. He sees the suggestions as a sea change, particularly allowances for added duty time for second- and third-year residents, as well as situational exceptions that allow residents to work longer to ensure continuity of care.

“The draft turns the old concept of professionalism 180 degrees by telling residents that sleep deprivation is no longer a lifestyle choice,” adds Dr. Fried, MD, MS, FACP, assistant professor of clinical medicine at Columbia University, vice chair for education in the Department of Medicine and director of Graduate Medical Education at St. Luke's-Roosevelt in New York City. “Residents must explicitly believe that it is their personal responsibility to work rested and free of fatigue in most cases. Furthermore, the draft makes explicit the rare but real situation in which the care of an individual patient supersedes the duty hour restrictions.”

In an editorial, members of the ACGME Duty Hour Task Force also argue that their recommendations should be viewed as more than a singular recommendation on how many hours young doctors can work (10.1056/NEJMsb1005800).

“Although much of the debate has focused on establishing appropriate limits on resident hours,” the authors wrote, “the task force recognized that ensuring patient safety and providing an excellent teaching environment entail more than setting these limits.”

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