Shashank Parulekar, Department of OBGYN Times,
they are changing! When I was a resident in early eighties, there used
to be just two House-officers and one Registrar for the whole unit, and
the two senior units out of four used to have outpatients twice a week
instead of once so as to fill up the two extra days. I was in one of
them. We used to work the whole week, no day off, no night off, and
casual leaves granted only if the Boss was in an exceptionally good
mood. There were times when we would sit next to an eclamptic patient
for 72 hours at a time, allowed to go for a nature's call keeping
another resident as standby, and for food as a special favor if the
Registrar was kind. In July of this year, the Accreditation Council for Graduate Medical Education (ACGME) implemented new work-hour limits for all residency programs in the United States. The new requirements limit residents to 80 hours per week averaged over a 4-week period. Residents cannot work more than 18 hours straight; they must have at least 10 hours off between shifts and one 24-hour period off per week. An analysis of the results showed that the limited work hours resulted in an improved lifestyle with more sleep and more family time for residents. On the other hand, only 22% felt the quality of training had been improved by these limitations. Many senior residents felt that some of the "scut work" had been transferred from the junior residents to them, reducing the quality of their experience. There was a slight decrease in CREOG exam scores. However, there was no decrease in the number of elective major surgical cases the residents performed. | The
main factor behind the New York changes and a consideration in
establishing the new ACGME regulations is patient safety. Despite over
10 years of experience in New York, there is little objective evidence
to show whether limiting resident work hours actually improves medical
care. Because patient safety, adverse occurrences, and outcomes results
are dependent on so many caregivers and so many different factors, it
will be difficult to tease out the impact of shorter work hours on
these objective measures, but every effort should be made to identify
useful benchmarks so that the effects of these new residency
requirements on patient care can be measured. Improvements are not automatic. Loss of continuity in the management of an elderly postoperative patient with congestive heart failure versus pulmonary embolus versus myocardial infarction might be problematic. If the covering attending is more overworked as a result of having to fill in the hole left by decreased resident coverage, he or she might not be as available to help with these problems and teach residents. Because of limited call schedules, the senior residents might not have dealt with enough placenta accretes or postoperative hypotension to recognize and manage these emergent situations safely. On the resident training question, with the stricter time requirements, will it be possible to find time during the week to get all the residents together for teaching conferences? Changes in the structure of resident training are needed to adjust to today's crop of married, family-oriented residents. But innovative approaches will be necessary to ensure that the quality of training and the level of patient care are not diminished. October 2004 |
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