Thomas Nasca, CEO of the accreditation council for GME published, on October 28, 2009, an open letter to the medical community. It details the findings of a 16 member ACGME task force regarding the effect that limiting resident work hours has had on medical professionalism. Thanks to DB for bringing it to my attention.
My problems with this letter are severalfold, but can mainly be distilled down to the following. Dr. Nasca would seem to suggest that it is ACGME's belief that medical professionals, bound as we are by the oath of Hippocrates and motivated as we are by altruism, should not be held to the same standard as other industries when it comes to safety and work hour regulations.
Thus, while residents must not be forced to remain on duty for excessive periods, they must not be precluded from demonstrating the caring and commitment required of them as altruistic professionals. ACGME's standards, and the expectations of the public of the nature of enforcement of those standards, must match this important principle. It is here, as in other places, that the analogy with the airline industry fails. A pilot, running out of hours, can refuse to fly the plane, and the passengers are no worse off for the decision, other than the delay. The Neurosurgeon, faced with a patient requiring an emergency craniotomy, does not see an option to, nor does he or she want to say no. The patient struck by a car, with multiple trauma, acute rhabdomyolysis with hyperkalemia and acute renal failure, needs dialysis now, not after the Nephrologist has slept for five hours. The patient needs and demands no less, as does our vow of Hippocrates.
I vehemently, though respectfully, disagree, Dr. Nasca. It is here that the analogy to the airline industry is more appropriate than ever. No more is it ok for a pilot - who is responsible for over a hundered lives - to violate his work hour restrictions than it is for a neurosurgeon who has been awake for 14 hours to perform an emergency craniotomy despite the fact that it is only one life that is at stake. Taking care of patient needs in violation of duty hour restrictions is not the hallmark of professionalism. Quite the contrary. Lack of adherence to standards that are put into place for the explicit purpose of protecting patient safety is irresponsible and clearly unprofessional
Within the boundaries of reasonableness, and with a goal of patient safety, residents must demonstrate willingness to sacrifice for their patients' needs, being taught and given the opportunity to demonstrate the practical manifestations of altruism, the core virtue undergirding professionalism.
In this case, Dr. Nasca, I will vehemently and disrespectfully disagree by referring the above quoted text as 'BULLSHIT!' As professionals, it is not our job to "sacrifice" for our patients - unless you're referring to the whole enterprise of being a doctor as "sacrifice." On the contrary, it our mandate as professionals to remove ourselves from situations in which our own well being has the potential to come into conflict with that of our patients - just as any professional in any other industry should recognize when his or her interests come into conflict with the interests of those whom he or she is purported to serve. I don't know about you, but I don't want my doctor to be in any situation in which he may have to choose between my well being and his own.
I think the medical profession is going to continue to struggle with this issue until there is some kind of cultural shift toward a more rational conception of the doctor-patient relationship.
