Rise of the Napturnist
The best sleep I ever got was in the winter of 1996. I remember it vividly. It was effortless, natural, blissful. I had swiftly slipped through the early phases of non-REM sleep, skillfully side-stepping alpha and theta waves, leaving myoclonic jerks in my wake. There was a brief hypnagogic dream involving sun-swept landscapes, playful butterflies, and a field of rhythmically blowing lavender that waved me further along on my slumbering voyage. And then, magically, I was basking in the pillowy splendor of stage 4 sleep, delta waves soothingly serenading me into hibernation.
I had found the celebrated state of suspended sensory and motor activity characterized by unconsciousness and loss of voluntary muscle movement.1 I was asleep.
I was an intern, had just worked 36 continuous hours, and was driving a car.
ACGME Outlines Resident Duty-Hours Changes
I was reminded of this incident on June 23, when I reviewed the freshly minted recommendations from the Accreditation Council for Graduate Medical Education (ACGME) task force regarding duty hours.2 This proposal follows on ACGME’s 2003 report, which enacted such national resident duty-hour standards as the 80-hour work week, the maximum 24-hour shift (plus six hours for administrative time), and the requirement for 10 hours off between shifts.
Like the 2003 report, which has played a large role in the rise of academic HM, the 2010 recommendations have major implications for academic hospitalists and our community brethren who will receive our residency graduates. As such, the reaction within the hospitalist community was immediate. Within minutes of ACGME’s notification, I was inundated with e-mail from colleagues both locally and nationally. Everyone was struggling with the repercussions. Was this good for resident education, a boon or bust for HM, a death knell for teaching hospitals?
So What’s in There?
This hotly anticipated report focuses its energy on four key elements of what the ACGME has morphed from “duty hours” into the resident “work environment”: resident supervision, handoffs of patient care, use of systems to enhance patient safety, and the effects of sleep on performance. Much of this is not really controversial and likely good for both residents and HM—an emphasis on systems-based practice, transitions of care, and expectations around communication.
The most discussed and controversial changes regard the move toward supervision and work hours that are customized to trainees’ levels. Unlike in the past, when the intern bore the brunt of the hours and patient duties, this proposal emphasizes graded supervision and duty-hour expectations. Practically, this means first-year residents will require closer supervision (whether by a resident or an attending has yet to be delineated) than more senior residents. Likewise, although all residents can only work a maximum of 80 hours averaged over four weeks (no change from 2003), the maximum shift length for interns will be limited to 16 hours. Upper-level residents will be limited to no more than 24 consecutive hours with an additional four hours for administrative work, but it is “strongly suggested” that residents working longer than 16 hours be provided with opportunities for “strategic napping.”
Read the Tea Leaves
I think these recommendations are rational and reasonable. To be sure, when these go into effect on July 1, 2011, they will have a tremendous impact on my residency program, my hospital, and my hospitalist faculty. My program, like most, likely will move toward a shift system of patient care, instead of overnight call. My hospital likely will have to expend millions of dollars annually to back-fill the work that residents would have done. My hospitalist group likely will have to expand our nonresident coverage both during the day and at night, inducing one of my partners to query, “Does this mean we’ll have to hire napturnists to cover the residents’ strategic nap time?”
