On Friday November 4th Thomas Nasca MD, the Chief Executive Officer of the Accreditation Council for Graduate Medical Education (ACGME), released a letter outlining the proposed changes to intern work hour restrictions and other regulations. Specifically, the proposed update is expanding the previous restrictions to the length of the intern (who is a physician in their very first year out of medical school) work day from 16 to up to 28 hours. Strong opinions regarding the proposals have been shared by veteran physicians, medical educators, medictudent and resident groups. Overall, I have felt encouraged that these commentators have all shared the common goals of improving patient safety and resident satisfaction. Unfortunately, I do not feel the same way about the attitude and statements made by the ACGME.
Since the release of the proposals, there has been much controversy and discussion about the increased limit to intern work hours and the impact on patient safety and thy mental health and well-being of resident physicians. It is important to note that in addition to easing restrictions, some of the changes proposed by the ACGME involve changing or clarifying the language of specific regulations (such as changing the term “Duty Hours” to the more politically preferable “Clinical Experience and Education Hours”). These changes highlight the importance of language to both the ACGME and physicians as a whole. For this reason, I am shocked and disheartened to see the manipulative and misleading statements made by Dr. Nasca regarding the state of residency training.
In his letter, while introducing the relaxed restrictions on intern work hours, Dr. Nasca states that “just as drivers learn to drive under supervision in real life, on the road, residents must prepare in real patient care settings for the situations they will encounter after graduation.” For me, learning to drive involved a slow and steady progression that rarely involved high intensity maneuvers or extreme situations. I was never expected to drive after being awake for over 24-hours, especially when my driving would put countless others at risk. Long hours, overnight shifts, and management of your own levels of stress and fatigue are all very important and necessary parts of physician training. Residency is not like learning to drive. Learning to drive is not associated with a 650% increase in the incidence of depression. The first year of residency is. However, by comparing these two situations, Dr. Nasca is downplaying the stress and difficulty of this process by conjuring memories of learning a fairly simple skill. If we cannot even acknowledge that residency is a grueling experience that threatens the mental and physical health of young physicians as well as countless patients, how can we claim that we are interested in everyone’s well-being?
Similarly misleading, according to Forbes magazine, Dr. Nasca “said in an interview that not even half of medical specialties ‘ever come close to’ 80 hours of residency work in a week'”. Although this is a common sentiment amongst the public at large, it has been shown to be false. Multiple studies have demonstrated that up to 83.6% of interns have violated the duty hour Clinical Experience and Education Hour restrictions. In fact, in a survey of 6,200 residents, over 50% reported violating the 80-hour work week at least a quarter of the time, and more than 40% admitted to under-reporting their hours so as to appear to abide within ACGME compliance. Dr. Nasca’s statement represents a blatant attempt to manipulate the public’s opinion of resident physicians. It makes any concerns about fatigue and its effect on patient safety seem like whiney complaints raised by underworked house staff. How can we have effective dialogue when the organization that controls graduate medical education makes false statements that discredit the trainees they govern?
If we are truly vested in maximizing both patient safety and physician well-being, we need to do away with the political posturing and media manipulation. We need to stop the adversarial relationship forming between the ACGME and the resident physicians they govern. The first step to achieving this is realizing that language matters.
The ACGME is collecting comments on the proposed changes until December 19th. You can view these changes and download the comment form at the following website: http://www.acgme.org/What-We-Do/Accreditation/Review-and-Comment.