Work Hours

I have blogged a lot about work hour rules in the past, but this time I would like to write about the new changes. All residency programs run under the purview of the ACGME, a regulatory body and accrediting organization. The ACGME recently issued a new set of work hour rules that will come into effect next year. The total number of hours a week is the same (80 hour limit) but the maximum shift length is changed. While there are many nuances to this, the general big-picture is that interns (first year residents) can only work a maximum of 16 hour shifts; residents can only work a maximum of 24 hours. The justification is that there should be gradation in training, and as one progresses through residency, they should gain more and more responsibility as the workload increases. This is notably a big difference from the philosophy of yore. In the "old days," intern year was the most difficult year, a trial by fire, and each subsequent year would become easier as one gains a more supervisory role.

However, these rules create an even more fundamental change in the structure of residency programs, especially in pediatrics and medicine. While other specialties such as anesthesia and ob/gyn are more amenable to shift work structures, medicine and pediatrics have traditionally been structured with overnight call cycles. The new work hour regulations decrease the flexibility of residency programs a lot, in essence mandating a shift work structure.

Whether this is right or not is a moot point; residency programs must comply with it. Thus, this is effectively a forced paradigm shift in the education of medical residents. The call cycle that has persisted for decades must be replaced by shift work. However, this provides an opportunity for those interested in medical education to do a complete rehaul of the system. Similar to Descartes' thought process in Meditations on First Philosophy, it is time to undermine the foundation of everything existing and decide what things ought to be rebuilt.

Indeed, this is the attitude Stanford has with regard to the residency program. In determining the structure of rotations next year, the only guidelines are the program's philosophy and the ACGME regulations. Of course, many elements will stay the same, but I think this will be a great opportunity to prune those activities that aren't educational and to emphasize the importance of resident well-being.