Académique Documents
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[Name] 11/1/201111/30/2011
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Special Report
Dates
Figure 1. Sample Schedule of Surgical Intern on Surgical Oncology Rotation, November 2011.
The average number of hours worked by this intern is 79 per week, for a monthly total of 316 hours, 8.5 of which are spent in clinic and
10 in conference or didactics.
agree with one another, we emerged with a fundamental shared concern: the uniform implementation of the rules has left the profession
without a mechanism for adequate evaluation.
Our profession would never accept a new drug
or device without clinical trials delineating benefit and risk. Why assume that any less is at stake
in implementing a new training system?
As Sanjay Desai, director of the internal medicine residency program at Johns Hopkins, remarked, Everybody says were done with duty
hours and we cant go back. Thats a defeatist
attitude. This is the future of American medicine,
and the risk is too great. Creating more regulation in the absence of data is not a tenable
solution.
The path of least resistance is simply to accept the rules weve been handed. But to create
delivery systems that are ultimately suited to
meeting patients diverse health needs, investigators must be able to study different approaches.
Right now, such assessment is impossible. We
therefore propose that the ACGME grant training programs a research exemption to permit
such investigations.
nejm.org
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The
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Table 1. Changes in Accreditation Council for Graduate Medical Education (ACGME) Work-Hour Requirements, and Comparison with Institute of Medicine (IOM) Recommendations.*
Variable
Maximum hr per week
Maximum length of duty
period
Additional duty hours
80
80
80
24 hr
Additional strategies
Ke y Data
For the public, the most compelling data are
those suggesting that practicing medicine while
sleep-deprived is akin to working while drunk.6
For instance, a 2004 study comparing reduced
work hours with standard schedules showed that
interns working longer hours had higher rates of
attentional failures, as defined by the intrusion of slow-rolling eye movements on continuous electrooculographic monitoring while awake.7
Being tired, of course, is something everyone
understands, so data on harms wrought by sleep
deprivation make sense intuitively. Indeed, a recent study showed that 80% of Americans surveyed would want to see a different doctor if they
knew theirs had been working more than 24
consecutive hours.8
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A Pr op os al
Though the ACGME must be accountable to both
the public and the profession, the publics voice
has often been louder than ours. When a patient
dies after a medical error, the emotional salience
of the event often trumps the imperative to accurately discern cause and effect, leaving us more
receptive to anecdote than hard data. Cases such
as Libby Zions have captivated the publics imagination. As Susan Day, cochair of the ACGME
task force, notes, Increasingly, the public feels
that it has a right to understand, and in a way
direct, how people are trained as physicians.
Undoubtedly, both proponents and opponents
of work-hour reform believe they are doing the
right thing for our system. But without a robust
evidence base, it is too easy to justify our intui2048
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Special Report
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