18 5 Percent For Internal Medicine Programs example essay topic

Sleep loss and fatigue may also cause harmful medical errors. Although the widely publicized Institute of Medicine report entitled To Err Is Human focused attention on patient safety, it had little to say about physicians' work hours. Elsewhere in this issue of the Journal, Gaba and Howard summarize data about fatigue among clinicians and the safety of patients. Although it is difficult to prove that sleep deprivation impairs clinical performance, they conclude that most relevant studies do show impairment.

Physicians must care for patients when they need care, regardless of the time of day or the convenience or inconvenience to the clinician. Their responsibilities often do not end when they leave the hospital. Despite the belief that better-rested physicians will provide better care, shorter working hours could have deleterious effects. There is less continuity when the caregivers for a given patient change frequently. Each handoff creates opportunities for miscommunication, delays in providing care, and mistakes. A study of the effect of the 1989 New York State regulation that restricted the working hours for residents found that the restrictions were associated with delayed ordering of tests and increased rates of in-hospital complications.

Another study found that the occurrence of potentially preventable adverse events was strongly associated with coverage by a physician from another house-staff team, which may reflect management of cases by residents who are unfamiliar with the patients. A counterargument is that the additional physicians may discover problems or make diagnoses that would otherwise have been missed. When physicians spend fewer hours with their patients, it is more difficult for them to observe and respond to changes in their patients' conditions. Residents may also perform fewer operations or procedures. Although there are no data demonstrating that an 80-hour workweek for residents is optimal, it has emerged as the standard.

According to the Council on Medical Education of the American Medical Association, scheduled work hours should be limited o avoid accumulating a sleep debt that leads to deterioration in performance. The council claims that most adults should average eight hours of sleep per night or 56 hours of sleep per week. To control for fatigue, most individuals should have at least five hours of sleep to work beyond 24 consecutive hours. To receive and maintain accreditation, residency programs must comply with common requirements and the standards for their specialty. The sponsoring institution must comply with institutional requirements.

Each year, the ACGME, in conjunction with its residency-review committees, conducts about 2100 site visits of programs, according to Dr. David C. Leach, the council's executive director. Each accredited program is visited an average of once every 3.7 years, and the maximal time between visits is 5 years. If a program loses its accreditation, it will lose its residents; to be eligible to take board examinations, residents must complete an accredited program. After the ACGME conducts site visits of programs, it takes "adverse actions" against about 8 percent.

Adverse actions include probation, a formal warning, and withdrawal of accreditation. Of 99 general-surgery programs reviewed by the ACGME in 2001, 18.2 percent were cited for violations of duty-hour and related requirements, according to council statistics. Citation rates were 21 percent for thoracic-surgery programs (19 programs reviewed), 18.5 percent for internal-medicine programs (81 programs reviewed), 11.4 percent for pediatrics programs (35 programs reviewed), 9.6 percent for family-practice programs (136 programs reviewed), and 5 percent for obstetrics and gynecology programs (81 programs reviewed). Among institutions that sponsor training programs, the rate of adverse actions is higher about 30 percent. However, since the ACGME began conducting institutional reviews about a decade ago, no institutions have lost their accreditation.

Although the council does not publicize adverse actions or make public the specific reasons for them, the accreditation status of each program is listed on the ACGME Web site. Programs must inform current residents and applicants about adverse actions. The ACGME conducts follow-up site visits to determine whether the problems have been resolved..