Today's NEW ENGLAND JOURNAL OF MEDICINE discusses new recommendations by the Institute of Medicine (IOM) that address an old and nettlesome problem: the long hours American medical residents must work during their training, and the impact that the resulting fatigue has on patient care. In an article entitled, “ Revisiting Duty-Hour Limits–IOM Recommendations for Patient Safety and Resident Education,” author John K. Iglehart takes a historic look at the problem, reminding us that the hours worked by residents came under intense scrutiny following the 1984 death of Libby Zion in a New York hospital, leading ultimatley to New York State's establishment, in 1989, of an 80-hour work week for residents.
The recommendations are not exactly earthshaking. The report calls for: “alleviating fatigue and loss of sleep among trainees, increasing their supervision by more senior physicians, improving the process by which responsibilities for patients are transferred from physicians going off duty to those coming on, and stiffening enforcement by initiating federal oversight of the regulations established by the ACGME” (Accreditation Council for Graduate Medical Education). The 80-hour work week remains in place.
The IOM apparently believes that the hours are not the problem. It is the non-adherence to the regulation, and underreporting of hours by residents, who do not accurately report duty hours for “fear of repercussions from their supervisors or, at the extreme, fear of causing a training program to lose its acceditation,” according to Mr. Iglehart. The second key problem has been poor communication by tired residents during “handoff” procedures.
Clearly, the IOM's report and recommendations are well thought out and timely. The question is, how studiously will they be followed?
A cynical answer appears in an article in today's NY Times , entitled “ Expert Panel Seeks Changes in Training of Medical Residents .” Reporter Tara Parker-Pope consulted Dr. Peter Lurie, deputy director of Public Citizen's Health Research Group, who said that “doctor hours should be regulated by the government,” and felt that the IOM's report would not make a difference in the quality of patient care.
“It's unlikely to be enforced,” opined Dr. Lurie. “It gives the appearance of taking the problem seriously, but, in fact, will likely maintain the status quo.”