High-Quality Learning for High-Quality Health Care

Abstract

IN JULY 2003, THE ACCREDITATION COUNCIL FOR GRADUate Medical Education (ACGME) established common residency program requirements that, among other provisions, restricted the number of hours the 100 000 residents in the United States can be on duty. In the 3 years that followed, the duty hour sections of the common requirements have received considerable attention from the media, the public, and the academic community. Comments have ranged from praise of the limits as critical to better patient care and learner safety and well-being, to predictions that they will spell doom for professionalism and continuity of care. The ACGME established duty hour limits with the goal of ensuring high-quality learning and safe, effective care in teaching settings. At the same time, the ACGME accreditation focus extends far beyond resident hours. Its review committees use information on the curriculum, the quality and engagement of faculty, institutional resources, supervision, educational outcomes, and the results of evaluations of residents, the faculty, and the program to determine accredited programs’ substantial compliance and suitability to educate residents. Information about programs’ performances includes input from more than 30 000 residents annually via a confidential Web-based survey (with response rates of about 90%) and confidential interviews of 10 000 to 12 000 residents during the more than 2000 accreditation visits ACGME conducts. The ACGME accredits 120 specialties and subspecialties, each with varying patterns of patient care and service demands as well as particular and time-tested learning environments. Every specialty has responded to the challenge of a single standard for duty hours by examining the resident hours that needed to be reduced to come into compliance, the extent to which activities important to attainment of competence could occur within a new model of learning, and the individual program’s ability to replace the clinical contributions of residents after the institution of the limits. However, duty hour reform is not an end unto itself. Three aims unite the ACGME and the GME community in the redesign of the learning environment: safe and effective patient care, high-quality resident learning, and resident safety and well-being. Changing only one variable (duty hours) in a complex system may, in fact, detract from achieving these aims. Comments from residents and others underscore the dual nature of the residency, highlighting that elements of the clinical environment and the learning model are linked, with both affected by the limits. A poignant example of this comes from a resident who completed the narrative section of the anonymous ACGME survey: “I’m sure we are in compliance with all of your requirements and yet both patient care and my education have gotten worse. Now I am here alone at night – there used to be two of us; one had to go home. I am looking after his patients as well as my own; I don’t know his patients. The faculty is busy doing work I used to do.” (ACGME Resident Survey 2005-2006, unpublished data). The health care system has depended for decades on the vigilance of overworked residents; changing duty hours calls for a different model of patient care and a different model of resident learning. It is a large undertaking. While there is a great deal of evidence that sleep deprivation compromises all 3 aims, there is little evidence that complying with duty hour requirements either increases sleep or improves the 3 aims. Most residents report that they use the extra time made available by duty hour reform to study or simply to have a more normal life; they do not necessarily spend the time sleeping. The continued heavy reliance on residents for clinical services, the added intensity of the fewer hours they now work, and the associated reduced availability of residents as caregivers require that other changes be made in both the patient care and educational systems. Changing duty hours, in the absence of other changes in the learning environment, may make patient care less safe. A systematic review examined interventions to reduce resident hours without other changes in the education and patient care system. It found that common approaches to reduce duty hours solely through scheduling changes such as night float and cross-coverage systems produced identical or worse outcomes of mortality, adverse events, and medication errors.