“To use an old model of education and training in a new model of work hours may not work.”
“But these studies are important for
us to review and will be part of the dis- cussion at the ACGME on how to begin thinking about duty hours requirements going forward,” Dr. Weiss said. “To use an old model of education and training in a new model of work hours may not work. An important question is: How is graduate medical education adapting to these new work hours, and how are we using new tools of education to allow residents to train differently?”
The 2011 Accreditation Council for Graduate Medical Education (ACGME) rule restricting intern hours is one of the bigger changes among reforms intended to improve patient safety, residents’ edu- cation, and their quality of life by reduc- ing fatigue for physicians-in-training. Several recent studies suggest the
rule may have missed the mark. Re- ported increases in patient handoffs and medical errors and less preparation of interns to take on more senior roles con- tribute to an overall perception that shift limits diminish the quality of residents’ training and potentially patient care. For Dr. Sorrell, now in her second
year, the changes translated to some lost opportunities. In medical school, her program in-
cluded rotations modeled after the for- mer 30-hour overnight call shifts. But as an intern, instead of following patients for 24 hours to see how the cases de- velop, she often had to hand them off as her shift ended. “We don’t get as much continuous exposure [to patient cases] during their initial work-up, and without that, the learning curve has become steeper af- ter intern year,” she said. “For me, a lot of informal teaching and learning with the attending happens in the down time, and now some of that gets lost because the work-hour limits are so structured.” Programs, too, had to make signifi-
52 TEXAS MEDICINE June 2013
cant adjustments both financially and structurally to adapt to the duty hours, with little obvious benefit to patient care, says Curtis Mirkes, DO, a member of the Texas Medical Association’s Council on Medical Education Academic Physicians Subcommittee. “Every program that has residents has seen some sort of effect — either neutral or negative — on patient care.”
More importantly, the new standards may change the way medical trainees approach medicine. “The mentality of the learner has gone from a more tradi- tional type of work to a ‘shift’ mentality; from ‘This is my patient to take care of no matter how long it takes,’ to ‘This is my patient until 5 pm.’ ” said Dr. Mirkes, who directs the Texas A&M Health Sci- ence Center College of Medicine internal medicine residency program at Scott & White Healthcare in Temple. The issue is the subject of ongoing re- view by and a top priority for ACGME, says Kevin B. Weiss, MD, senior vice president for patient safety and institu- tional review. But he reiterated that the new rules came from legitimate public concern over patient deaths perceived to be related to resident fatigue. Teaching hospitals and residency pro-
grams are just now beginning to adapt to the changes, so it’s too early to say whether the work-hour limits are meet- ing their intended goals, he says.
Shifting the limits In 2003, ACGME began regulating resi- dents’ work when it established the 80-hour workweek. The move came in response to public concern that resident fatigue contributed to medical errors and patient deaths and to congressional demands for federal oversight. A subsequent 2008 Institute of Medi- cine (IOM) report found the initial re- forms did not go far enough and high- lighted studies showing the detrimental effects of fatigue on clinical performance. The IOM report called for additional
revisions to medical resident duty hours aimed at improving patient safety, as well as residents’ learning experience. Those recommendations included:
• Maximum shift lengths and defined off-duty periods;
• Greater supervision of residents by experienced physicians;
• Adjusted workloads based on resi- dents’ level of training;
• Structured handoff processes, and • Restricted moonlighting.
In 2010, the ACGME Board of Direc-
tors approved broader reforms in line with the IOM recommendations, but only after what Dr. Weiss described as a lengthy, multistakeholder process. It included input from across the medical profession and deliberations on avail- able research on the impact of sleep is- sues, patient safety, and resident training. The most significant change was re- stricting first-year residents to 16 hours of continuous duty, down from 30 hours. For residents in year two and beyond, shifts dropped from 30 to 28 hours. The thinking was interns were more suscep-
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