NO CLOCK-PUNCHING

Another concern brought up in the JACR article hints at something more resistant to quantification, and perhaps closer to the heart of the profession, a worry that insisting on residents "clocking out" at a specific time could create a culture of time-serving or clock-watching hostile to the spirit of medicine.


"If you get residents used to a culture where their job ends at 5 o'clock or 3 o'clock, then you're not teaching them that as part of being a physician you have to put the patients' interest above your own. You have to look after the patient, if it means you stay a little later," Dr. Mainiero says. "[If you're not] adhering to a strict patient mentality, it's not good what you're teaching the next generation about what it means to be a physician," she says.

It could also result in "hand-off" errors, which a report in the New England Medical Journal noted in Dr. Mainiero's article argues are known to occur when a patient transfers out of a resident's or doctor's care at the end of a shift.

The IOM also acknowledges these errors exist, and recommends instituting structured hand-off procedures, as well as training residents in how to better pass along patients.

"Everyone pretty much admits in medicine that hand-overs are a risk, period," says Dr. Dinges. "That may be true, but fix hand-over. Make hand-over better."

NEXT STEPS

But whether any or all of these recommendations get adopted is up to the ACGME, which is still reviewing the IOM suggestions, after a congress was held this summer in which doctors and residents got to comment about the proposed changes.

"We expect in July their new recommendations," says Dr.Mainiero.

Whatever they choose, Dr. Dinges hopes the IOM report "will stimulate an ongoing dialogue, as opposed to entrenching positioning." And that doctors can work together to find out how to ensure that traditions of intensive training to produce the best doctors can be preserved, while also minimizing risks to patients - and the residents themselves - from lack of sleep.

"The evidence is the evidence," says Dr. Dinges. "If you come at the problem from the side where the suggested changes might produce more hand-over...risks and make less well-trained physicians, you can see why there would be an adamant response. But if you approach it from the other side - tired doctors making mistakes is not something I want to hear about."



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