Resident duty hours and professionalism theme of second issue of JGME

CHICAGO, January 4, 2010 – The second issue of the Journal of Graduate Medical Education( JGME) has been released to the web and mailed to 10,000 qualified recipients, including program directors and designated institutional officials at accredited programs and institutions throughout the US, and members of the Accreditation Council for Graduate Medical Education (ACGME) Board of Directors and Review Committees.  

JGME was launched as the first peer-reviewed journal dedicated entirely to the education of medical residents and fellows and the settings in which it occurs. The inaugural issue of JGME was released in September 2009 to highly positive reviews by the graduate medical education community. 
The Journal is of interest to members of the GME community, including program directors, graduate medical education leaders, faculty, learners and researchers. It serves as a vehicle for the dissemination of research, innovation and scholarship in graduate medical education, with a particular focus on practical approaches than can be adopted and adapted in a range of settings. 
The September and December issues of JGME are available for open access at www.jgme.org.

December Issue Highlights:

Companion Editorials Explore Resident Work and Learning
The December issue of JGME explores multiple linked themes, including resident duty hours, resident burnout and professionalism, with several articles devoted to each of the four topics. “We purposefully selected articles at the interface of the dialogue about resident hours, professionalism and resident burnout, given the dialogue started by the publication of the Institute of Medicine Report recommending new limit on resident hours.  We added a fourth topic, simulation in resident education, as a means of overcoming the limitations of basing resident learning solely or largely on experience with real patients,” says Ingrid Philibert, PhD, MBA, JGME managing editor. 

A guest editorial by Kenneth Ludmerer, MD, offers a retrospective of resident education that explores the origins of resident burnout and its potential links to increased intensity of residents’ work, and their growing disconnectedness from their faculty. Dr.  Ludmerer emphasizes that limits on resident hours are needed for a variety of reasons, but limiting resident hours does not address and may compound problems arising from the profound effect of clinical pressure on resident education. 

“The new rules do not guarantee adequate amenities while on call, a faculty that knows and cares about the house staff, stimulating conferences and rounds, the ready availability of advisors and mentors, a fair policy about parental leave, the immediate accessibility of help, or a strong sense of camaraderie,” Dr. Ludmerer says. “Limiting resident hours does not address the larger and more fundamental issue of working conditions."

The second editorial by Richard Satava, MD, looks at the future of medical education, with a focus on simulation as a tool and means to enhance education and reduce reliance on actual patient care experiences. 

The power of simulation is that it allows individuals to experience errors and failure in a safe environment (the simulated setting). Dr. Satava notes that if learners lack opportunities to experience error in such a safe setting, they “will continue to make the same mistakes repeatedly until they figure it out themselves by trial and error [poor teaching method] or the errors are clearly and unambiguously explained to them. Then and only then will the students be able to avoid making errors, or if an error is committed, to identify the error and immediately remediate.” 

Dr. Satava highlights team training and hand-over training to provide continuity as exciting opportunities for simulation.  An emerging use of simulation is to allow physicians to rehearse specific care actions and procedures immediately before performance on a real patient.  “All other professionals (e.g., basketball, soccer, symphony, dance) warm up before performing their skill, and recent data confirm the benefit of this process to surgeons,” Dr. Satava states.  Articles in the simulation section of the December issue describe a range of applications of simulation, spanning both the simulation laboratory and in situ applications.

Two Descriptions of a Trial of the IOM-Duty Hour Recommendations

Two articles authored by residents summarize chiefs’ and interns’ perspectives of a one-month trial of the Institute of Medicine recommended limits on resident hours. 

Stephanie Tessing, MD, a first-year resident during the trial, and colleagues report that fully conforming to the IOM recommendations addressed some problems, but created a host of new issues requiring solutions. They emphasize the need to change the current model of resident education.  “Whether good, bad, or indifferent in its elements, the experience with a shift work model highlighted one salient point: residency training needs to undergo a culture change,” Dr. Tessing concluded.

In the companion article, Katherine Auger, MD, and colleagues, chief residents at the time of the study, declare that implementing a shift model to conform to IOM recommendations is feasible, but will require a sizable (25% to possibly 50%) increase in the resident workforce to care for the same number of patients.

Dr. Auger and colleagues also highlight the need for change in the education model.  “Further trials of the IOM recommendations are needed prior to widespread implementation in order to learn what works best and causes the least harm, disruption, and unnecessary cost to the system,” they concluded.

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The ACGME is a private, non-profit council that accredits approximately 8,700 residency programs in 130 specialties and subspecialties educating 108,000 residents. Its mission is to improve health care by assessing and advancing the quality of resident physicians’ education through accreditation.