Keith Foster, PhD
Advances in technology have made direct observation by video recording or live-feed easy and affordable, allowing the most financially limited programs to conduct direct observation this way. It is not surprising, then, that a large number of family medicine residency programs use some form of video recording or live-feed direct observation.
What is surprising is the absence of or only passing reference to the issues of informed consent, patient authorization, and procedural guidelines related to video recording and live-feed precepting in the examining room, particularly in the age of HIPAA.
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.