2010 duty hour standards: seeing beyond the numeric limits.

To the Editor: In the March 2011 issue of Mayo Clinic Proceedings, Antiel et al1 report that a sizable percentage of program directors in internal medicine, pediatrics, and surgery believe that the 2010 Accreditation Council for Graduate Medical Education (ACGME) duty hour standards will negatively affect residents' acquisition of the ACGME competencies, will reduce continuity of care, and will not relieve resident fatigue. This finding is concerning and runs counter to the aim of the standards. It may be helpful to point out some limitations of the study. One is its predominant focus on the numeric limits. This ignores the focus on safety and quality, supervision, teamwork, transitions of care, alertness management, and residents' professional development. The authors do not report program directors' comments on these elements of the standards, which were added in response to input from experts in quality and safety, fatigue and alertness management, and the medical community at large, who suggested the standards needed to go beyond a set of numeric limits that would “make care safe and learning effective” and optimize residents' professional development. One enhancement to the 2010 standards is that residents are allowed to remain and care for their patients when it is important from a patient safety, educational, or humanitarian consideration. Another limitation is that the survey was completed in July 2010, two months before the ACGME released the final standards. At the same time Antiel et al fielded their instrument, the ACGME sought input from the education community and received comments from more than 1000 organizations and individuals. In late August 2010, the ACGME Task Force made minor yet important revisions to the standards, including no longer stipulating that the frequency of in-house call could not be averaged. An article from the same survey data shows that, other than the 16-hour limit for first-year residents, this standard generated the most negative reactions.2 The ACGME learned the same from feedback from the education community, which led to a return to the time averaging permitted under the standards currently in effect. Finally, although program directors' perceptions of the standards are important, real benefit will come from work to test interventions that enhance resident learning and acquisition of competence under the standards. This includes the work by McCoy et al3 published in the same issue of the Proceedings. Their article showed that implementation of a night float system compliant with the 16-hour limit had no negative effect on quality of care metrics, including length of stay, readmissions, and mortality, and that a small increase in intensive care unit transfers may represent appropriate decisions by alert residents to move patients to a higher level of care. This kind of work makes a major contribution to the duty hour literature by exploring ways to enhance learning and patient care. The science on sleep and performance, despite its limitations, appears incontrovertible to the public, which expects an alert physician. Residents make up approximately one-seventh of the physicians in the United States. As the accreditor for graduate medical education, the ACGME's role is to promote trust by seeking to bridge the gulf between public expectations for an alert physician and educators' expectations for educational time and rigor to ensure that graduates are prepared for independent practice. Ignoring public concern about resident fatigue carries the risk of public distrust and the threat of legislation ending a cherished tradition—the privilege of professional self-regulation.