August 2, 2011

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AN ABUSE OF PATIENT TRUST

Stating that the hours residents work is “an abuse of patient trust,” patient safety expert Lucian Leape has attacked the new limits on first-year residents’ shifts set by the Accreditation Council for Graduate Medical Education (ACGME). Starting July 1, they can work no more than 16 hours without sleep. However, ACGME will continue to permit shifts of 28 consecutive hours for more senior residents, including surgical residents.

In a white paper published in the current online issue of Nature & Science of Sleep,¹ coauthor Leape says the new rules for residency training don’t incorporate best patient-safety practices. Coauthor Charles Czeisler, MD, states that extensive research shows experience doesn’t overcome the need for sleep and that no justification exists for maintaining unsafe work hours. Fatigue is a safety concern not only for resident physicians but for nurses, attending physicians, and other healthcare workers. Indeed, key recommendations of the white paper serve as a model for limiting excessive work hours for all healthcare personnel:

•    limiting all resident work hours to shifts of 12 to 16 hours
•    making ACGME work-hour compliance a condition of participation for Medicare GME support
•    identifying in real time– and intervening—when a resident physician’s workload is excessive
•    requiring attending physicians to supervise all admissions
•    mandating in-house supervision for all critical-care services, including emergency care
•    making fatigue management a Joint Commission National Patient Safety Goal
•    redesigning residents’ workload to maximize educational value; much of what residents currently do could be done by other hospital personnel
•    providing transportation to all residents too tired to drive home
•    including “moonlighting” in work-hour limits. Hospitals should establish formal policies and monitor resident physician moonlighting.


¹Blum AB, Shea S, Czeisler CA, Landrigan CP, Leape. Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety. Nature and Science of Sleep. 2011 Jun;2011(3):47-85. DOI: http://dx.doi.org/10.2147/NSS.S19649

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