IMPLICATIONS OF THE 2011 ACGME DUTY HOUR RULES

In May 2010, Dr Thomas Nasca, Accreditation Council for Graduate Medical Education (ACGME) CEO, outlined the process of revising the 2003 duty hour requirements. He stated the overriding principles of patient safety and excellent patient care in teaching settings, delivering outstanding education today to achieve these goals in the future, and educating residents in a “humanistic educational environment that protects their safety, and nurtures professionalism and the effacement of self-interest that is the core of the practice of medicine and the profession in the United States.” He continued,

It should be emphasized that all 3 of these principles are equal, and must be fulfilled. They are not mutually exclusive goods; they are absolute ‘goods’ and must be achieved. Furthermore, those principles and their articulation in standards go far beyond the issues of resident duty hours.¹

Program directors certainly agree with these principles. A majority of family medicine program directors in a 2009 study, however, disagreed that Institute of Medicine (IOM) duty hour recommendations (which significantly contributed to the ACGME final requirements) would help to achieve these absolute “goods.”² Over 70% believed patient access to care would decrease; over 90% thought the rules would exacerbate a “shift-worker mentality” in residents; over 80% believed they would result in “graduating doctors who are not experienced enough to practice independently;” and over 90% thought they would result in “graduating doctors who generally take less ownership and do not know patients as thoroughly as in the past.” Over 80% did not believe the duty hour changes would result in residents “becoming more compassionate, more effective family physicians;” in fact, only 0.8% believed this would occur.

In July 2011, the ACGME’s revised duty hour rules went into effect, in part based on voluminous research into the effects of fatigue and sleep deprivation on performance, but also due to external political pressures that forced the ACGME to take action and try to preserve the vestiges of a profession before Congress, governmental agencies, and activist groups forced more draconian measures. Considering the previously surveyed opinions of program directors, one can draw 2 conclusions concerning the impact of duty hour revisions on the quality of our residents’ education and on patient care. The first possibility is that program directors collectively were wrong and that the duty hour changes will in fact result in better family physicians and improved care for patients. This is 1 circumstance where most program directors hope they were indeed wrong.

The other possibility is that the collective wisdom of the group responding was generally correct. Regardless, Congress, advocacy groups, residents, and recently graduated family physicians (who may not fully appreciate their level of preparedness or have a basis for comparison) will not likely agree to go back to less restrictive duty hour rules. Assuring adequate experience levels for independent practice, teaching professionalism, and providing residents a glimpse of the joy of deep and meaningful patient relationships needs to be addressed in new ways.

John Wooden said, “If you don’t have time to do it right, when will you have time to do it over?” The realistic answer is never, CME reforms notwithstanding. As family medicine educators, we need to get it right the first time! As the effective amount of training time continues to diminish (1 estimate is that a resident now will train the equivalent of 2.4 years compared to a 3-year residency of the past), we owe it to our residents and the public to honestly and actively study the length of family medicine residency training to minimize any unintended negative impact of duty hour restrictions. Producing quality family physicians cannot be even partially sacrificed for other important goals such as meeting primary care workforce needs. We need to assure that a board-certified family physician stands out from mid-level practitioners and other generalist physicians, both in scope of practice and skills. This may require more time than we currently give ourselves to provide our residents the new skill set needed to lead in the future health care system.

• © 2011 Annals of Family Medicine, Inc.