Correspondence
Residents' Duty Hours and Professionalism
N Engl J Med 2009; 361:930-931August 27, 2009
- Article
To the Editor:
The Accreditation Council for Graduate Medical Education (ACGME) is currently reevaluating its 2003 rules1 regarding duty hours, in light of the recent recommendations2 from the Institute of Medicine (IOM) regarding additional limitations. Although the financial costs incurred in the initial implementation of the rules were substantial and the projected financial costs of further limitations are daunting, another cost, left unaddressed by the IOM task force, is even more troubling to many of us who are involved in graduate medical education. We have transformed the trainees in our core programs from dedicated professionals into shift workers.
When the duty-hour rules of 2003 went into effect, we scheduled our residents' duties to fully use the available hours. We took away their control, preventing them from making the decisions that characterize a professional. We now force them to leave a patient with whose treatment they are intimately involved or to cease the observation of an instructive surgical procedure midstream. It did not take long for this system to produce residents who would either walk away when their time had expired or else lie in order to violate the rules. Although we added “professionalism” as a training goal, we began giving our trainees the choice between abandoning a patient and lying.
We must return professional decision making to the residents. Of the 80 hours per week they are allowed to work, no more than 75 hours should be formally scheduled. These assigned hours need to be monitored, and violations should be subject to ACGME sanctions. The remaining 5 hours should be left purely to the discretion of the individual residents, to use however they see fit; there should be no expectation that they will provide clinical services to the program during these hours. These hours should not be subject to any specific restrictions but should be limited only by the resident's assessment of his or her level of fatigue. If a resident feels it is important to give up an hour on a day off to meet with a patient's family or to stay an extra hour observing an unusual case, it should be allowable. We are required to teach our residents about recognizing fatigue, and this approach would allow us to verify that learning in a supervised setting.
If we fail to make this change to our training system, we will end up with a large number of medical workers, not medical professionals.
John D. Rybock, M.D.
Johns Hopkins School of Medicine, Baltimore, MD
rybock@jhmi.edu This letter (10.1056/NEJMc0905152) was updated on May 18, 2011, at NEJM.org.
2 References- Citing Articles (1)
Citing Articles
1
JULIA E. SZYMCZAK, JOANNA VEAZEY BROOKS, KEVIN G. VOLPP, CHARLES L. BOSK. (2010) To Leave or to Lie? Are Concerns about a Shift-Work Mentality and Eroding Professionalism as a Result of Duty-Hour Rules Justified?. Milbank Quarterly 88:3, 350-381
CrossRef
