Starting July 1, 2017, the ACGME duty hour requirements will be tweaked. Interns will be allowed to work a full 24-hour shift — up from 16 hours — followed by up to 4 hours for activities related to patient safety, education, and effective transitions. This follows their senior counterparts — residents in years 2 and up, whose shifts were limited to 24 hours. Gone also is the curious “strategic napping” clause, which was suggested for residents on their 24 hour shifts as an “alertness management” strategy.
ACGME Duty Hours Addressed Concerns of Resident Exhaustion
What is the difference between a physician who is intoxicated and one who has not slept in 24 hours? The answer: not much. In a landmark study, Williamson and Feyer compared volunteers who were sleep deprived and those who were intoxicated. They found that a person who has stayed awake for 24 hours functions with the same diminished cognitive skill of someone with a blood alcohol level of 0.10. This study — and many others — reveal the dangers of sleep deprivation and prolonged duty hours.
In 2003, under pressure from OSHA (the Occupational Safety and Health Administration) and other regulatory bodies, medical educators responded to these data by crafting mandatory duty-hour requirements that are familiar to many. Residents could work a maximum of 24 hours with 4 hours for transition time and education. Residents could work a maximum of 80 hours per week averaged over 4 weeks, must have one day off in 7, and must have at least 8 hours off between shifts. As I mentioned, the ACGME even called for naps. Interns, however, were singled out. Citing their increased workload, the maximum number of hours for an intern shift was 16.
Did We Get It Right?
We in residency education have been scratching our heads if ACGME duty hours are appropriate. Are 80 hours a week too many or too few? Are residents missing valuable experiences monitoring the course of illness with their patients? How much rest does a person need between shifts — 8 hours? 10? 12?
While the advent of duty hours was thought to herald a new era of safer, higher quality medicine, there have been unintended consequences that may have adversely affected the learning culture — most significantly, a negative impact on education. An important systematic review showed that an emphasis on duty hours had no impact on patient care outcomes or resident wellness. Also, residents found they had less time or were less likely to attend teaching conferences. Another systematic review among surgical programs showed an inconsistent effect on resident wellness and a negative impact on patient outcomes and performance on certification exams. The FIRST trial compared surgical trainees following the ACGME duty hours with those with more flexible duty hours. There was no difference in patient outcomes and resident satisfaction with well-being and education.
Have we focused more on the importance of duty hours at the expense of the learning climate? At the expense of the patient? An intriguing study randomized pediatric interns to the standard 30 hour, q-4 day call schedule and 12 hour shifts in compliance with duty hour restrictions. Surprisingly, educators found that the shorter shifts led to an increase in burnout possibly because of an increase in workload intensity. One intern remarked, “You feel like you do EVERYTHING for every single patient. It’s like carrying the entire patient load the entire day (like typical call night – but for the daytime calls too!), and you never sat down, never.” Another study showed that residents often had conflicting values in reporting duty hours. They felt an obligation to the patient, but then often lied about their duty hours out of fear of punishment from program leadership or adverse consequences from the ACGME.
Conversely, some residents may adopt a “shift mentality” where one clocks in and out, switching on and off patient care with the flick of a pager button. This tendency challenges an archetypal model of physician professionalism where true commitment means seeing the case through to the end, no matter the sacrifice. And yet, shift-work does not reflect life after residency when duty-hour restrictions no longer exist.
Many in the medical community and general public are debating these trade-offs —16- versus 24-hour shifts for interns, 80 versus “the old days” prior to 2003, when duty hours did not exist — and that debate is valuable in this time of change, but perhaps the most important aspect of the new common program requirements is getting the least attention. I believe there is a much more powerful sea change intended in the new common program requirements: an emphasis on workplace culture.
The Joy of Curiosity
Perhaps the most important aspect of the new common program requirements is getting the least attention. The new ACGME requirements emphasize the importance of creating a healthy learning environment for trainees. Consider this: the section that used to be called “Resident Duty Hours” has been changed to “The Learning and Working Environment.” The new requirements then follow with an entire section that speaks directly to institutional culture. They cite the importance of “Excellence in professionalism through faculty modeling of the effacement of self-interest in a humanistic environment that supports the professional development of physicians (and) the joy of curiosity, problem-solving, intellectual rigor, and discovery.”
The effacement of self-interest… a humanistic environment… the joy of curiosity. This language is a far cry from The House of God. In fact, they are filled with promise. For instance, at a site visit, it is now fair game to be asked, “How is your institution fostering the joy of curiosity?” The ACGME is to be applauded for making a humanistic environment a priority in medical education. A toxic environment leads to cynicism and suboptimal patient care.
These ACGME common program requirements are the template upon which we build our residency programs. As program directors follow the ACGME’s lead, how will we address these new requirements? It is much easier to track duty hours than it is to address the effacement of self-interest.
More to the point, how does this help patients? Is a more curious physician prone to make fewer mistakes? A more joyful one? Is joy a replacement for sleep? Time will tell.
Benjamin R. Doolittle, MD, MDIV is an expert in burnout and wellness in residents and physicians. He is an associate professor and program director of internal medicine and pediatrics at the Yale University School of Medicine and the medical director of the Yale Medicine-Pediatrics Practice.
How do you feel about the changes to ACGME duty hours and the ACGME’s apparent shift in attitude about the culture of medical training?