Today, CIR National President Dr. Farbod Raiszadeh of the Committee of Interns and Residents/SEIU Healthcare, the nation’s oldest and largest union for resident physicians, released the following statement in response to the proposal by the Accreditation Council for Graduate Medical Education (ACGME) to restructure medical residency positions:
In evaluating the impact that the proposed changes laid out by the ACGME will have on the safety and quality of care that resident physicians are able to provide for our patients, not to mention our own safety and wellbeing, we cannot escape the conclusion that the new training rules do not go far enough to protect patients and residents.
The ACGME’s proposal and article in the New England Journal of Medicine comes more than 18 months after the Institute of Medicine (IOM) issued landmark recommendations to improve the safety of patients and the resident physicians who care for them. Although clearly the ACGME has spent a lot of time thinking about work hours and supervision for housestaff, their proposal stops well short of implementing key aspects of the IOM’s recommendations as laid out in Resident Duty Hours: Enhancing, Sleep, Supervision, and Safety and inadequately addresses the body of scientific evidence that clearly states that marathon shifts in excess of 16 hours can have a detrimental effect on a physician’s abilities and judgment.
Limiting shifts to no more than 16 consecutive hours for interns – medical residents in their first postgraduate year – is wise, but the ACGME should not have stopped there. First-years represent only about 22% of the 106,000 interns, residents and fellows in the U.S. The IOM’s 2008 recommendations, put forth by a panel of experts after an exhaustive 12-month review of the literature, do not make a distinction between interns in their first year of training and residents who are in their second, third, or eighth year. Acute and chronic sleep deprivation affects the clinical performance and judgment of all human beings. Moreover, patients seeking care in teaching hospitals deserve to know that the resident physicians taking care of them are rested and alert – not fatigued to the point of impairment working shifts of 30 consecutive hours with little or no sleep.
The Committee of Interns and Residents has long stressed that work and medical education re-design is essential to improving patient care and physician training. It is not just about hours worked – it is about what residents do in those hours. We are taught over and over again to practice evidence-based medicine. Yet on this subject, so many of our senior medical leaders refuse to recognize the evidence that fatigue leads to an increase in preventable medical errors.
While acknowledging that work redesign is not always easy, we know that reducing marathon shifts is possible, and we have catalogued examples across the country of innovative medical educators who have already reduced resident work hours to safer limits. It can be done, but without the ACGME insisting that it must be done, the unsafe status quo will remain in place.
That unsafe status quo also extends to the fatigued residents themselves, who are at greater risk of car crashes and occupational injury from needlesticks when they are sleep-deprived. The IOM report calls on hospitals to immediately begin providing residents with a safe way home. The ACGME proposal does not even mention it.
Finally, the IOM report called for rigorous oversight on the part of the ACGME, including unannounced visits, strengthened complaint procedures, and confidential, protected reporting of hours by teaching hospitals. This last point is particularly important. We know that residents often do not accurately report their hours because they are afraid of retribution. Additionally, the penalty for violating work hours limits – putting a program on probation or losing its accreditation – hurts the residents themselves. While the ACGME’s new plan is more rigorous, it still relies on residents blowing the whistle and the penalty still hurts residents, so we should not expect any better results. The Committee of Interns and Residents supports the IOM’s recommendation that both the Centers for Medicare and Medicaid Services and the Joint Commission play a role in holding the accrediting body more accountable for the quality of care and the training conditions under which resident physicians work.
Although we commend the ACGME for thinking seriously about these issues, we remain alarmed that the end result will perpetuate working conditions that are fundamentally unsafe both for resident physicians and our patients.
If you would like to speak with a resident physician on this topic, please contact Tim Foley, CIR’s Director of Communications: (212) 356-8126.
For additional information on how to establish evidence-based work hour scheduling for resident physicians that optimizes the quality of patient care, resident education, and safety, go to www.hourswatch.org