published online 23 February 2009.
Article Outline
The American Gastroenterological Association (AGA) Institute greatly appreciates and agrees with the sentiment of the Institute of Medicine1 (IOM) that ongoing evaluation and reassessment must be made of the American College of Graduate Medical Education (ACGME)'s requirements to the adjustment of residency hours in the hopes of further reducing the risk of medical error owing to fatigue and sleep deprivation. In the subspecialty of gastroenterology, this is particularly cogent where emergency situations such as gastrointestinal bleeding and acute liver failure mandate around-the-clock availability. Furthermore, the gastroenterology subspecialty service is often needed to make definitive endoscopic or cognitive recommendations in an effort to salvage critical situations and optimal mental acuity and judgment is mandatory.
Subspecialty care, however, is structured differently than specialty medicine. Examples of the different structure of an inpatient gastroenterology or hepatology consult service include the following.
1.In contrast with a team of residents caring for an inpatient service, there is usually only 1 fellow assigned per service and perhaps even an entire hospital without other subspecialty fellow backup.
2.As opposed to a specialty house staff team usually caring for a geographically defined group of patients, subspecialty fellows cover an entire hospital and all its services.
3.The role of the attending on a specialty service involves cognitive rounding and teaching as the main function, which usually can be accomplished in a few hours; additionally, in gastroenterology, performance of procedures is an integral part of the service responsibilities. As a result, the gastroenterology attending's daily time commitment to the service requires the entire day to enable the service to function by working synergistically with, but not instead of, the fellow in the required clinical care.
4.The subspecialty service gets “stretched” to some degree already when subspecialty fellows attend their required weekly, half-day outpatient clinic, usually covered by the attending on service. A similar problem applies to vacation in the first clinical year of fellowship.
5.In contrast with specialty training, upper level fellows are committed to research blocks, potentially including year-long, required daily class time for a master's degree, which further limits the pool of covering subspecialty fellows available to accommodate a reduction in duty hours.
Given these caveats, the AGA Institute addresses the IOM's proposals in the following manner.
1.The authors wholeheartedly support the maximum 80-hour work week and the 30-hour shift maximum.
2.We agree with the maximum on call every 3rd night as an absolute without averaging and agree with a specified number of hours off between shifts depending on shift length.
3.We agree with moving to 5 days off per month with a minimum of 24 hours off per week and 48 hours off per month.
4.We agree that both internal and external “moonlighting” should be counted against the 80-hour week.
On the other hand, the IOM needs to consider or clarify certain issues for our subspecialty including the following.
1.The question of whether “at-home call” time of a subspecialty fellow is equivalent to the “in-house call” time of a specialty resident. Although at times considerable, the demand is not at the same level as in-house specialty resident call. The question of when “at-home call” becomes “in-house call” or “shift work” has not been formally addressed by the ACGME and, therefore, gastroenterology program directors are left interpreting this issue on a program-by-program basis.
2.Coverage for a subspecialty fellow, particularly during the day, will be much more difficult. The fellow functions as the singular point source for subspecialty care on the inpatient service in the hospital with little or no backup clinical fellow coverage available, and the gastroenterology attending already has a full-time commitment to the gastroenterology service. As a result, a 5- to 6-hour nap time for fellows could not be readily covered by attendings and we question how useful the nap concept would actually be.
3.The complexity of the patients covered by typical gastrointestinal and hepatology services, for example, liver transplant, inflammatory bowel disease, and fulminant pancreatitis, are such that physician extenders would have a very difficult time covering the fellow's absence unless they were already an integral part of the inpatient care team. Unfortunately, the assignment of a physician extender to all inpatient gastrointestinal and hepatology consult teams is most likely to be prohibitive in cost. Similarly, to expand the fellow and/or attending physician cohort as another option to allow for some of the recommendations would also be financially prohibitive to many medical centers. The former would also require approval by the ACGME Residency Review Committee for each institution.
4.Before further reductions in hours worked by specialty residents and fellows occur, including those suggestions that leave gaps in continuity during the day, the largest stakeholders (patients) should be polled as to their opinion of these proposals. One has to wonder if we understand the emotional impact of these changes on the physician–patient relationship and how it will affect patient care.2 This is particularly important at the level of the subspecialty resident, who is often seen as the main point person for the service in academic institutions.
5.In lieu of having general requirements for hours worked in a hospital throughout all stages of training, perhaps it would be more appropriate to have duty hour requirements tied to the intensity and nature of the work performed instead of to the number of hours consumed, having shorter working times in high-acuity settings with less experienced trainees (eg, an intern in the intensive care unit) and having longer working times in less acute settings with more experienced trainees (eg, upper level residents on general medical floors or fellows on inpatient consult services). From the viewpoint of a gastroenterology fellow, this might apply to the high intensity of a busy liver transplant service versus a more manageable endoscopy rotation.
6.As physicians who evaluate and treat patients, we continue to be distressed by the discontinuity of patient care and lack of ownership involved in residency training that has occurred since the 80-hour duty work week requirements went into effect. It is often difficult to identify the specialty resident who is responsible for a particular patient. To complicate matters, the outpatient primary care physician turns over inpatient care to a housestaff team, often with a different medical attending as well. Therefore, it is prudent to maintain as much continuity of care at advanced levels of training (eg, at the subspecialty fellow level) as possible. Additionally, we suggest that formal instruction on how to effectively hand off a service should be included in the medical school curriculum and/or residency orientation and taught by physicians who are themselves experienced with this system. As discussed by Babatsky et al2 “the goals of training are to train competent physicians who assume full responsibility for their patients”; this must be our top priority.
We welcome comments and look forward to continued dialogue as we all strive to provide optimal patient care in the best possible educational environment.
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References
- Ulmer C, Wolman DM, Johns MME. Resident duty hours: enhancing sleep, supervision and safety (Institute of Medicine of the National Academies). Washington, DC: The National Academies Press; December 2008;
- Babyatsky MW, Bazari H, Del Valle J. Opportunity or challenge in resident work duty hours: the Institute of Medicine Report. Gastroenterology. 2009;13:
