The American Council for Graduate Medical Education (ACGME) is issuing new guidelines for the amount of time interns and residents may work at one stretch. The new guidelines prescribe no more than 16 hours straight for interns and no more than 24 hours straight for more senior residents. In each case, a transition time of 4 hours is to be allowed in order to hand over patient care from one doctor to another. The ACGME acknowledges that there is no data to support concerns for trainees beyond the first year (internship) but does site data suggesting that after 24 hours judgment becomes impaired and medical errors are prone to increase.
We certainly applaud any advocacy for patient safety and agree with outlining guidelines for physicians in training. However, the fact of the matter is that we have only marginally increased the number of physicians being trained overall in the United States over the past two decades. Additionally, we have minimally expanded, or not expanded at all, the number of resident positions, especially among medical and surgical specialties over the same period of time. The Association of American Medical Colleges (AAMC), which oversees medical education in the US, embarked on a review of manpower and launched an enrollment expansion to increase the number of graduates by some 30% by 2015. That is the good news. The bad news is that they are about 20 years too late.
Unfortunately, a perfect storm of events is conspiring to exacerbate the physician shortage and its effects.
First is the too long delayed expansion of medical school enrollment, which has made no sense, since the US “imports” physicians via the ECFMG portal (Educational Commission for Foreign Medical Graduates) to the tune of nearly 10,000 per year since 1992. In a nation of over 300 million, this makes no sense at all. America, the melting pot of the world, has ample diversity from which to select all the physicians we need.
Second, the aging of the medical profession as a whole with the attendant attrition brought on by death and retirement. For example, within medical education institutions themselves the average medical faculty age was 41.7 in 1967, 44.7 in 1987, and 48.5 in 2007. The percentage of all faculty over 55 years old was 9% in 1967, 19% in 1987, and 29% in 2007. Over these decades, the average age of first-time assistant professors pursuing research increased from 33.6 to 39.3 years old. The average age of all first-time faculty, regardless of entering rank, increased from 35.3 in 1987 to 37.8 years old in 2007.
Third, the increasingly hostile reimbursement environment compounding the already hostile liability situation creating impetus for senior physicians to reduce work hours, restrict complex cases, reduce overall case loads and take early retirement. Many, many physicians who are in the prime of their careers (age 50-60) are seriously considering opting out of medical practice altogether.
Fourth, the expansion of health insurance coverage that is in progress under recently passed legislation will lead to major overcrowding of doctors offices, clinics and hospitals. Like it or not, physicians are human, and they will vote with their feet if the medical practice environment becomes too burdensome.
In the end, the true practice of medicine does not lend itself to strict hours, punch cards or time clocks. However, it would seem that the educational, health policy and reimbursement structure are being attuned to “force” physicians, beginning at the earliest point in their training, into an employee mindset. This concept fits nicely with the administrative needs of a federally run system, which is the goal of this administration, many in Congress and among a large number within the profession as well. In the end, the private practice of medicine, as we have known it, will likely be preserved only in boutique manner with those being able to afford a real personal physician, being able to access one. The rest will have to queue up and wait while the doctor changes shifts, so that he/she can be sure to get enough sleep . . . jomaxx and obi jo
New Rx for Young Doctors: Shorter Work Day – http://online.wsj.com/article/SB10001424052748703900004575325130511028968.html?mod=WSJ_hps_sections_news
The New Recommendations on Duty Hours from the ACGME Task Force – http://content.nejm.org/cgi/content/full/NEJMsb1005800
ACGME TASK FORCE ON QUALITY CARE AND PROFESSIONALISM: PROCESS FOR DEVELOPING RECOMMENDATIONS ON NEW SUPERVISION
AND RESIDENT DUTY HOUR STANDARDS Executive Summary – http://acgme-2010standards.org/pdf/Executive_Summary.pdf
Projections of Future Medical School Enrollment – http://www.aamc.org/data/aib/aibissues/aibvol9_no3.pdf
The Aging of Full-time U.S. Medical School Faculty: 1967-2007 – http://www.aamc.org/data/aib/aibissues/aibvol9_no4.pdf
Coming to America International Medical Graduates in the United States – http://content.nejm.org/cgi/content/extract/350/24/2435
Educational Commission for Foreign Medical Graduates – http://www.ecfmg.org/