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Dr. O retires after four decades of dedication
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Instructions: Radiology Imaging Studies Available via Web
Residents' work hours: a new era
by: LAWRENCE M. SHUER
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Stanford Hospital & Clinics is actively involved in the training of interns, residents and fellows in a wide variety of medical disciplines, and this role carries with it certain responsibilities. Not only must we make sure we are providing our trainees with a quality education, but we must also make sure we are doing so in a healthy, constructive environment.
In previous columns I have discussed the requirements for keeping each of our residency programs certified by the Accreditation Council on Graduate Medical Education's Residency Review Committees and, in turn, by the ACGME as a whole. This coming February, our institution is scheduled to be surveyed by ACGME to assess our compliance with the council's regulations and standards. At that time, a representative will review our training programs to make sure we have the necessary faculty, infrastructure and working conditions to be accredited as an institution that houses such programs. At our last survey, in 1997, we received a five-year accreditation - the maximum allowed under the current system.
In our upcoming survey, some of the issues that will be assessed involve how we plan to institute the ACGME's "core competencies" into the training of our residents, and how we will measure our success in achieving this goal. Still, the most high-profile issue will likely be the accreditation council's new mandate that resident training hours be limited to 80 hours per week and that no resident work more than 24 hours at a stretch. These requirements will take effect in July 2003. At our survey review, the site visitor will be looking to see what plans we have made to reach this target and will assess our current status regarding residents' work hours.
Indications are that the ACGME is serious about this matter. One major East Coast medical school has already had one of its residency programs placed on probation for "excessive" house staff hours.
Many of us no doubt wonder: Why is the ACGME so concerned about house staff hours? After all, most of us had no limits on our work hours as residents - and most of us worked more than 80 hours a week on a regular basis.
Legally speaking, the stage for the current requirements was set with the Libby Zion case in New York. In that case, an adverse patient outcome was judged to be directly related to a medical resident being overly tired from working excessive hours. Since the Zion case, New York state has legislated limits on how many hours per week residents can work. This has greatly influenced the way New York teaching hospitals function and the way they run their residency programs.
The ACGME says it views the residents' work-hours issue as strictly a patient safety issue rather than simply an effort to control the way residents are trained. The council points to data demonstrating that sleep-deprived individuals have higher error rates in settings such as flight simulators and in tasks requiring quick decision-making and manual dexterity. David Gaba, Stanford professor of anesthesia, has demonstrated similar results in evaluating personnel running mock codes in his patient simulator at the Veterans Affairs Palo Alto Health Care System.
Undoubtedly, the new limits on residents' work hours will change the culture of medicine and medical education into the foreseeable future. Whether this change will be a positive one, only time will tell. Nonetheless, it seems such limits were bound to be imposed sooner or later. I understand that in some European countries, residents' work hours are restricted even more stringently than our 80-hour limit.
Regardless of our personal or professional feelings about limiting residents' work hours, there is no value in arguing with the ACGME on the merits of this new regulation. We must therefore be creative in designing our resident schedules in a way that allows us to fully comply while continuing to provide high-quality patient care and an excellent education for our trainees.
Please drop me an e-mail at lshuer@stanford.edu or give me a call at 723-5371.
