Editorials

Resident Hours: Reform Is at Hand

Am Fam Physician. 2002 Oct 15;66(8):1398-1399.

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The Association of American Medical Colleges (AAMC) has been hard at work as a member organization of the Accreditation Council on Graduate Medical Education (ACGME) to place an 80-hour limit on weekly resident hours and otherwise limit resident time on duty. For almost two decades, AAMC has advocated an 80-hour limit as part of a comprehensive policy on graduate medical education that also calls for appropriate resident supervision, quality education, and effective institutional oversight and support. There is no question that action by ACGME was needed to respond to legitimate concerns, both outside and within the profession, about patient safety and resident well-being. The public and its representatives in government have made clear that the profession needs to address this issue effectively or face the very real possibility of government regulation.

I believe the hard work has paid off. On June 11, 2002, the ACGME board accepted the report of its Work Group on Resident Duty Hours and the Learning Environment, which recommended establishing reasonable limits on weekly hours, continuous hours on duty, and the frequency of night call. The AAMC supports the changes adopted by the ACGME, which has taken a giant step toward achieving the proper balance between the educational need for continuity of care and the need to protect the interests of patients and residents. The new rules will go into effect in July 2003.

Having taken this important step, ACGME now must turn its attention to the critical task of implementation. Once the new standards are approved and incorporated into program and institutional requirements, ACGME must strengthen its monitoring and enforcement practices. The pace of ACGME review must be quickened, and programs found to be in violation of the new standards must be held accountable. Uncompromising oversight of Institutional Review Committee (IRC) and Residency Review Committee (RRC) enforcement decisions by the Council will be essential for ensuring equitable and uniform compliance.

Effective implementation, I believe, will be key if we are to avoid federal intervention into this quintessentially professional arena. Some, including the American Medical Student Association and The New York Times, have advocated federal restrictions on residents' duty hours because they believe the profession is incapable of mounting sufficiently firm self-regulating mechanisms to do a credible job.

In keeping with this sentiment, Rep. John Conyers (D-MI) and Sen. Jon Corzine (D-NJ) have introduced bills in Congress that would etch such limits into federal law. The AAMC is steadfastly opposed to this approach on both principled and practical grounds. In principle, abdicating our obligation as a profession to regulate our educational affairs in the public interest would signal a disastrous retreat from a time-honored fundamental tenet of medicine's social contract—and invite still further erosion of professionalism. In practice, professional self-regulation has a much greater potential for success than does one-size-fits-all federal strictures. The complexity, variability, and unpredictability inherent in the learning environments typical of graduate medical education cannot be accommodated adequately in any set of government regulations. Setting and enforcing limits on resident hours clearly is a job for knowledgeable, experienced professionals, but that job will remain ours only so long as the public has confidence that its interests are being satisfied.

The AAMC will continue to work with the ACGME to strengthen its enforcement activities. We also will work with our member programs—most of which already are in full compliance—in adapting to these new rules. Since 1999, an AAMC task force has been studying innovations designed to rebalance eduction and patient care in residency programs. In some areas, simulators and computer-based tutorials have been introduced to improve resident education. In others, expanded employment of nurse practitioners and physician assistants has relieved residents of certain patient responsibilities. I anticipate that the pace of innovation will increase. The Association will continue to seek out promising innovations and share the news of best practices, including sound approaches to analyzing the cost and other impacts of these practices, among our members. We are sure to see significant, positive changes in graduate medical education over the next few years—an outcome everyone can applaud.

Jordan J. Cohen, M.D., is president of the Association of American Medical Colleges, Washington, D.C.

Address correspondence to Jordan J. Cohen, M.D., President, Association of American Medical Colleges, 2450 N Street N.W., Washington, D.C. 20037.


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