Otolaryngologists View Resident Work-Hour Restrictions: ACS calls for in-depth investigation before mandating further restrictions

An in-depth national study needs to be conducted to distinguish the effects of fatigue points, said Dr. Healy, the current President of the ACS, and the first otolaryngologist to hold that position. We know that fatigue points differ between individuals, and medical providers may not fatigue as easily as surgeons due to physicians’ ability to accomplish tasks in ways other than in direct patient care.15

According to Dr. Johns, There are potential loopholes in the 80-hour workweek as it pertains to otolaryngology programs. Most otolaryngology residents take home call, which does not count toward total duty hours unless they are physically called into the hospital. However, residents may be paged numerous times throughout the night, disrupting sleep.

Outside the United States, otolaryngology and other surgery and medical specialties are likewise engaged in these ongoing discussions. At end of the pipeline, said Dr. Sachdeva, it is imperative to scrutinize the knowledge and skills of residents graduating from training programs with fewer work hours than in the US and their preparation for independent practice.

To produce the same product-that is, the competent and skilled surgeon-there would be no choice but to lengthen the duration of training, and that presents several huge problems. Funding is one. Longer training time, especially for subspecialties, would also lead to workforce shortages and to discouraging bright people from entering surgical specialties.

The IOM is currently reviewing data and receiving input from physicians and surgeons across the country as well as abroad. The ACS has distributed its report widely to all department chairs, program directors, CEOs, and specialty societies. The response has been extremely positive and readers appreciate the balanced view that is presented.

A well-organized national study with multiple arms conducted in multiple centers must be undertaken to truly answer some of these questions, said Dr. Healy. Without addressing these issues scientifically, we are jerry-rigging an old system to fit new needs.

In addition, said Dr. Johns, Both private and public payers need to recognize the importance of academic health centers in training the physicians of tomorrow. It is more expensive to operate academic health centers with teaching programs, and payer reimbursement should be commensurately higher to account for this.

ACGME Restrictions on Resident Work Hours

• Limitations of duty hours to 80 hours per week (an average for a four-week period; possible increase after approval by the Residency Review Committee)
• One day free in seven (averaged over four-week period)
• In-house call no more frequently than every third night (averaged over four-week period)
• 24-hour limit of on-site duty (with up to six-hour extension for certain activities)
• No new patients may be accepted after 24 hours of continuous duty
• Minimum 10 hours rest break between duty periods
• Callbacks to hospital during at-home call must be counted

References

1. Accreditation Council for Graduate Medical Education. Report of the ACGME Work Group on Resident Duty Hours. Chicago, 2002.
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9. Volpp KG, Rosen AK, Rosenbaum PR, et al. Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. JAMA 2007;298:984-92.
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10. Volpp KG, Rosen AK, Rosenbaum PR, et al. Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. JAMA 2007;298:975-83.
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11. Golub JS, Weiss PS, Ramesh AK, Ossoff RH, Johns MM, 3rd. Burnout in residents of otolaryngology-head and neck surgery: a national inquiry into the health of residency training. Acad Med 2007;82:596-601.
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12. Sachdeva AK, Bell RH, Jr., Britt LD, Tarpley JL, Blair PG, Tarpley MJ. National efforts to reform residency education in surgery. Acad Med 2007;82:1200-10.
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13. Sachdeva AK. Acquiring skills in new procedures and technology: the challenge and the opportunity. Arch Surg 2005;140:387-9.
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14. Sachdeva AK. Surgical education to improve the quality of patient care: the role of practice-based learning and improvement. J Gastrointest Surg 2007;11:1379-83.
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15. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004;79(10 Suppl):S70-81.
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