Guest commentary: New rules for residency programs will improve the culture of medical education
The Accreditation Council for Graduate Medical Education (ACGME)—the professional body responsible for overseeing the nation's residency programs--earlier this year announced new standards for U.S. residency and fellowship programs.
Not surprisingly, a single issue—allowing (not requiring) first-year residents to work up to 24 continuous hours—has drawn nearly all of the attention. That is unfortunate because it has diverted attention from the broader aim of the sweeping revisions the ACGME has made in the way the nation will train new physicians. As a whole, the changes will transform the culture of resident education itself, rooting it in high-quality care, patient safety, and physician well-being. And for the first time ever, residency programs will be held accountable for establishing and enforcing such a culture.
The modern U.S. residency system provides the core of every doctor's medical education. It is during the three to nine years after medical school that physicians come of professional age—acquiring the knowledge and skills of their specialties, forming professional identities, and developing habits, behaviors, attitudes and values for their professional lifetime. Residency training is meant to be a hands-on activity. Residents learn by actually caring for patients, observing the moment-by-moment changes of their conditions, and monitoring the results of diagnostic studies or therapeutic decisions that they themselves make, all under appropriate faculty supervision.
What the ACGME sought to do is strike a balance that gives residents the real-world experience they need to provide high-quality patient care over their lifetimes, while also ensuring patient safety and their own personal well-being. But let me be clear. No one wants a tired physician. Not patients, not physicians. And certainly not me, a practicing physician and member of the task force that produced the new requirements.
In the past, the residency system erred on the side of overworking residents. Through the 1990s, some residents worked more than 100 hours per week. The ACGME ended this with its first set of work hour rules in 2003, when it became the first oversight organization to take resident well-being seriously. This mandate continues in the new standards with the addition of requirements that provide much greater emphasis on the total circumstances of residents' lives—reasonable call schedules, obtaining adequate rest when not in the hospital, greater attention to wellness and personal health, and having care available for personal medical problems. The ACGME recognizes that residents (and all physicians) are at increased risk for burnout and hence requires that residency education be conducted in a nurturing, humane environment.
It is also important to understand what has not changed. The total number of clinical and educational hours for residents remains the same, a maximum of 80 hours per week. The rules also mandate one in every seven days be free from clinical experience or education, and that in-house call occur no more frequently than every third night. As for the maximum of 24 continuous work hours for all residents, it is a ceiling, not a floor, and the fact is most medical residents may never experience a 24-hour clinical work period.
Medical specialty committees can also restrict the hours further. For instance, the specialty of emergency medicine for years has capped shifts at 12 hours.
The change for first-year residents places them on the same schedule with other residents. A broad range of specialty program directors as well as residents themselves identified not being on the same schedule as a major problem. Integrating first-year residents back into the team creates better continuity of care and promotes professionalism, empathy and commitment among new physicians. The team can decide when it is time to hand off a patient or for the resident to go home. Residents are not forced to abandon patients or worried families when the clock hits an arbitrary time.
Other requirements make residency programs and their institutional sponsors responsible for placing greater emphasis on patient safety and quality improvement, for more comprehensively addressing physician well-being, for strengthening expectations around team-based care, and for creating flexibility to schedule clinical and educational work hours within the maximums. Equally important, the standards address fundamental issues such as providing residents manageable patient loads, relief from non-physician chores, closer intellectual and personal relationships with faculty members, and better supervision.
The greatest beneficiary of these changes will be patients. There is plenty of evidence that improving the supervision of residents, minimizing the hand-off of patients, and providing residents manageable patient loads improves safety and quality of care.
As a whole, the new standards set graduate medical education on a better course to do right by residents and patients.
Dr. Kenneth M. Ludmerer is a professor at the Washington University School of Medicine and served on the Institute of Medicine's Commission on Resident Duty Hours and on the ACGME's Task Force on Common Program Requirements. He is the author of "Let Me Heal" (Oxford, 2014), an account of the residency system in the U.S.
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