An essay in the Journal of the American Medical Association
warns of dire consequences for medical education and clinical outcomes if the U.S. follows Europe in instituting a 48-hour workweek for physicians and physicians in training.
But Dr. Thomas Nasca
, CEO of the agency overseeing the nation's residency programs, the Accreditation Council for Graduate Medical Education, said he agrees with the direction of the essay but adds that the trend the authors warn of—reduction in resident work hours—is not being considered.
Written by physicians and researchers from Massachusetts General Hospital and the Harvard Medical School, it's argued in the essay that the 48-hour work week for public employees mandated by the European Working Time Directive does “not explicitly address the unique nature of medical care.” Studies from the U.K. are cited, and the authors suggest that expert opinion on the “negative influence of work-hour reductions on clinical training was compelling.”
“The implications of the directive for medical care and medical education in the United States deserve serious consideration,” the authors concluded. “It is imperative to understand the consequences and implications of the directive before sailing further into this uncharted sea.”
Nasca said he agreed with the conclusion but added that the ACGME and its accredited institutions are not sailing anywhere in the vicinity the essay authors are suggesting.
“No medical educator has contacted me and asked for more limitations on duty hours,” he said. “But I can't count the number who have about the other direction.”
Nasca said there is a general consensus that the ACGME “got it right” with its limit of 80 work hours averaged over four weeks, but it's the “parsing” of those hours that needs to be refined.
He explained how 12 to 13 of the 26 specialties whose training programs ACGME accredits have had difficulties with new work-hour regulations
Nasca also agreed with an assertion in the essay that the work-hour limits—meant to reduce resident fatigue—can actually add to it.
“There clearly is evidence in some circumstances, for one reason or another, that institutions have chosen not to provide additional hands to provide services,” Nasca said. He added that this has resulted in the compression of resident work duties that are both more stressful and fatiguing than had been experienced under longer work hours.
But Nasca also noted how there is data that the 80-hour limit has allowed residents more time for sleep, and this has resulted in less fatigue and more satisfaction with their education.
“They now have sufficient time to have a life outside of medicine to do more besides sleeping and eating,” Nasca said.
He said, however, that there is also a major concern that work-hour limits
are leading to a shift-work mentality and reducing the sense of professionalism in a new generation of physicians.
Nasca explained that the direction of medical education is going toward teaching team-based medicine, but there are times when the complexity of patient's condition calls for them to be treated by the same physician. He said there are times when a fatigued physician who knows a patient best can deliver better care than a rested doctor who is totally unfamiliar with the patient.
The ACGME board is discussing this issue, Nasca said, and that the “devolving” of the physicians' role from professional to technician is what's at stake.
“That is the core element of the debate,” he said.