Joseph Scherger, MD, MPH
Throughout my career, I have been in favor of restrictions on resident work hours. After watching how surgery residents worked in the 1970s, I wanted none
of that “prison sentence.” After choosing family medicine, I found a program with “civilized” work hours. I do not think much learning happens after working 80 hours in a week, and patients do get harmed by residents who are too fatigued to care or use good judgment.
I embraced the 2003 ACGME resident work hour restrictions since they had flexibility but limited the on-duty time to 80 hours a week and guaranteed some days off each month. Residents could still sit with patients who were going through a long labor and delivery process or who were in end-of-life care. These long experiences are some of the most memorable for residents and do not occur too often to cause chronic fatigue. They showed the resident how well they can work under occasional extreme circumstances, a skill that would be valuable in a crisis.
The 2011 ACGME work hour restrictions are much more specific and prohibit the time for any “work shift.” First-year residents may no longer work on any given day more than 16 hours. That means that if the resident is with a woman in labor or at the bedside of a critically ill patient they must end their work and turn the care over to another resident. Second- and third-year residents must do the same after 24 hours and must be able to have a “strategic nap” after 16 hours. Is this the continuity of care of a family physician? No family physician in practice would ever consider such an abandonment of their patient! This is how emergency room physicians work, and I wonder if these new work restrictions will transform family medicine into shift workers.
There is evidence that we become less effective in our clinical judgment after 12 hours of continuous work and certainly after 16 hours. With that being so, we should train for teamwork where another physician joins us in the care of the patients after we become less effective. That would reinforce that we are not superman and should ask for help but would not take us away from the very situations where we may be doing the most good and are having a great learning experience.
I hope our leaders in the ACGME will make an effort to revise the resident work restrictions again to allow for both continuity of care and teamwork, so we can balance both clinical experience and patient safety.
Sam Cullison, MD
Anyone working in family medicine graduate medical education knows that the bar is being raised by the ACGME, as well as by society in general, to demonstrate that our residency graduates are truly prepared to show “sufficient competence to enter practice without direct supervision.” This is not a new standard for graduation, but the rigor with which we must prove residents’ ability is getting tougher.
Some of us (like me) were in the field when Dr David Leach first announced the six competencies in the late 1990s. We were warned that requirements would be progressively increased and that proving competence would require more than verifying time and clinical exposure, with faculty sitting around a table venturing abstract opinions based on recall and the group dynamics of the moment.
However, there is good news in all of this. We are being challenged to prove we know what we are talking about when we say a resident is ready to graduate. Being challenged to defend one’s beliefs is nearly always a good experience, since it requires reassessing assumptions and asking ourselves why we believe what we assert. And to build on that good news—assessing competency is not as tough to do as one might think. I am now a year into chairmanship of the Residency Competency Measurement Task Force, chartered by the Council of Academic Family Medicine and administrated by the Society of Teachers of Family Medicine. I came to the role with a lot of leadership experience but not much competency in competency measurement and tools. Fortunately, I have learned a lot from the other task force members and read tons of books and articles. I have decided that this can be done.
So, what is it going to take?
We have created a web-based Resident Competency Assessment Toolkit. I think it does a good job of walking faculty and directors through the tools available for competency assessment and how to use them.
A couple of general observations:
- The tools can be simple to use.
- One tool can be used to measure more than one competency. For example, I can use direct observation, (watching a resident care for a patient), to analyze medical knowledge, patient care, communication, and professionalism in one sitting.
- You can decide how many tools you want to use to measure any given competency.
- Multiple faculty watching a single resident provide care to different patients over different times accumulates a body of information on competency that is both valid and reliable, especially if forms are used to record findings and faculty have been trained together to create common standards.
- Feedback is valuable when received from sources outside the faculty: staff, patients, peers, and students.
- Learners love feedback, and more of it more often “normalizes” it and takes away the stress.
- There is no perfect form; do not spend time searching for “the holy grail” of perfect forms. Find one already in use elsewhere, modify as you must, and then start using it—frequently and by many assessors.
- Faculty need to work together to reach common definitions of competency. Otherwise, faculty assessing the same clinical events will reach very different conclusions.
GO FOR IT!!