The ACGME has published an open letter concerning work hours (h/t to @FutureDocs).  I highly recommend reading this letter, which I found balanced and nuanced.  Nasca Letter

Here are the big issues that I read:

1. Patient safety is the number one charge to the ACGME.  The committee cannot find data showing that decreasing work hours has improved safety.
2. We have an indirect safety concern – that of producing competent physicians.  Many observers worry that work hour restrictions are leading to less resident responsibility for patient care.  We work on a model of graduated responsibility, and many argue that we are losing responsibility in the later years of residency.
3. R1s need more work hour protection than do senior residents.
4. Work hour limits on one service have a negative impact on other services.  They also have a negative impact on faculty at many institutions.

This paragraph suggests that ACGME is listening to educators and residents:

This expectation (that absolute limits can be placed on a physician caring for patients) is a principal reason for concern. Most believe that it is a matter of professionalism that physicians must never be governed by the clock when a patient needs assistance. It is anticipated that residents will be placed in circumstances where they might be able to leave (or might be “expected” to leave), but a patient needs their continued assistance. Within the boundaries of reasonableness, and with a goal of patient safety, residents must demonstrate willingness to sacrifice for their patients’ needs, being taught and given the opportunity to demonstrate the practical manifestations of altruism, the core virtue undergirding professionalism. Thus, while residents must not be forced to remain on duty for excessive periods, they must not be precluded from demonstrating the caring and commitment required of them as altruistic professionals.

To this paragraph I can only add a BRAVO!  This paragraph states beautifully my greatest concern over strict work hour enforcement.

My GI blogging colleague – the WhistleBlower – gave me a heads up to this important surgical perspective – Resident Duty-Hour Cuts Said to Impair Surgical Education, Safety

Although the cap on working hours was designed to enhance patient safety by keeping exhausted residents away from operating tables and other aspects of patient care, rates of surgical complications and reinterventions actually climbed after the rules were imposed, they said.

Jackson and Tarpley recommended more flexibility in duty-hour limits for surgical residents in particular.

"Surgical disciplines are unique in that surgeons must not only acquire medical knowledge but also develop the manual dexterity and, sometimes, the strength and endurance to perform procedures," they said. "There probably isn't a shortcut for learning surgery."

So here is my modest proposal.  Give programs general guidelines.  Let each specialty decide on relevant details.  If surgery wants longer work hours in training, so be it.  Let each program decide how they will train residents, and publish their rules openly.

Then let students decide on programs with full knowledge.  Many students will still choose more challenging residencies (see my post earlier this week).  Some students will look for easy residencies.

I want a physician who trains in a tough, demanding residency.  You cannot learn medicine without appropriate volume. No one makes you become a physician.  If you want a less stressful residency, then you can choose one.  We should not prevent students and residents from learning medicine the old fashioned way; we just should not make them do that.  Make residency choice a free market of work hours and continuity concerns.  Let residents compete in a transparent open fashion.  I think that many will be surprised at how many students choose the tougher residencies.

Related posts:

1. Duty hours, patient safety and resident education
2. Duty hours – no easy answers (h/t @FutureDocs)
3. Work hours – medical student perspective
4. Adapting to work hour restrictions
5. Reform residency but intelligently

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