Duty hours: still up for debate?

Medical residents still work loooong hours, longer than most of us will ever work in a single week at a paying job: 80+ hours. But that’s down from much longer work-weeks, a mandate from the Accreditation Council on Graduate Medical Education (ACGME) after complaints that long hours were contributing to woozy residents, too sleepy to make the best decisions for their patients.

But in a recent New England Journal of Medicine article, NEJM editorial fellows Lisa Rosenbaum, M.D., and Daniela Lamas, M.D. argue that the ACGME may have implemented those new duty hour rules too hastily. Where, they ask, is the careful weighing of the evidence and examining of options that doctor-scientists hold so dear?

The ACGME acknowledges that the need to create a uniform standard has forced the development of rules that cater to the lowest common denominator, rather than allowing each specialty to mold an environment that suits its trainees’ learning needs and ambitions. “Standards are standards, and we tried to be flexible,” says Ingrid Philibert, ACGME senior vice president, “but my sense is we’ve created a rigid monster without flexibility.”

So what exactly should the ACGME go back to the drawing board on? Rosenbaum and Lamas say it’s the bigger picture that needs examining.

Both short-term and long-term outcomes should be considered. For instance, when assessing work hours, do we look at safety within the confines of a 16-hour shift, or can we examine the effects of a bad handoff 6 months after the fact? Equally critical, how do we understand what will happen 5 years down the road, when today’s trainee is suddenly facing 100-hour workweeks because that’s what it takes to get the work done?

Residents I’ve spoken to seem to have mixed feelings about the new duty hour rules, too (new, in that they were just revised last year and are taking effect now). They want to learn everything they need to in order to take the best care of patients, and some say that just takes a varying amount of time. I’d love to hear what others think.