IOM Report from Dec 2008

The Institute of Medicine (IOM) recently published a report on residency duty hours regulations. Basically, the report states that residents are still fatigued and that action is needed to guard patient safety. This report is a very serious document, and a response from ACGME was immediate. The next Annual Educational Conference of ACGME will take place in March, and it is expected that a lot of discussions and decisions on this matter will dominate the conference.

Here are a few comments on this new report (and on the survey that ACGME asked all residents to take):

1. Currently, there are no work-hour regulations that apply to attending physicians, who can therefore work an unlimited amount of time. An that choice is not always theirs to make; it can be imposed to them by their Division Chief or Chairman, just like my work hours can sometimes be imposed by my chief resident. Does this mean that current residents grow and develop their work mentality into a fake bubble of work-hour protection that has no application to real life? If I will have to work 100 hours as an attending, then learning to be a physician with a limit of 80 hours per week, is probably bad training. Is the public going to realize that attendings can also be over-worked and fatigued and demand work-hour limitations for them as well?

2. All the literature so far (see review in JACS, Nov 2008) demonstrates that the 80-hour work week regulations have decreased fatigue (at least chronic fatigue). However, there is no concensus on the effect of the regulations on the quality of training. The IOM 08 recoomendations seem that they will further decrease fatigue (maybe even have an effect of acute fatigue). However, only a few of the recommendations ("limit non learning time" etc) are designed to enhance education. If we keep cutting down the hours, without paying extreme attention to the methods of training and making changes to that domain as well, we risk "cutting down on education".

3. If the new IOM recommendations are approved and applied, there will be many duty-calls that will be uncovered by residents. This would mean that more residents need to be hired or more physician extenders need to be hired. The first solution costs money and also raises the concern that education opportunities will be divided to more people (this is mostly true for surgical residents, as the same number of total cases will be divided to more residents). The second solution is at least 4 times more expensive than the first solution. So, to the minimum these recommendations are very very expensive. Who will be asked to pay for this? Most hospitals (especially in today's economy) will refuse to put money into this; they will likely shut down their programs; and this is not limited to "small community hospitals". And I am sure that DoD and Medicare will be very excited to pour money into residencies. Money makes our world go round, so I think this will be the reason why the recommendations cannot be applied.

To conclude, I think that the ACGME will eventually adopt many of the new IOM recommendations, because the public wants at all cost to protect the patient safety. To the minimum, the new regulations will involve more strict and frequent monitoring of residency programs, less flexibility with violations and higher penalties for violating programs. The extend to which the recommendations will be adopted will be determined by the funding agencies. I do believe that these changes will improve residents' fatigue. On the other hand, I am very skeptical about the effect on training. I believe that in our era of expanding technology, endless paperwork in the hospitals and the transformation of patients into clients-customers, the way residents are being trained seems archaic. Changes are imminent and, I believe, necessary.