duty hours debate: does promoting patient safety necessarily mean further reductions in duty hours?

In December of 2008, the Institute of Medicine published a report titled: Resident Duty Hours: Enhancing Sleep, Supervision and Safety. I have to admit that I have only read the Report Brief and the table of recommendations found on their website, however, it appears clear that the report suggests modification of current ACGME rules for shift length (although not theoretically reducing the overall 80 hours), and tightening of monitoring processes by the ACGME are needed.

The report was published almost a year ago, why bring it up now? One of the Staff here at the Cleveland Clinic brought the open letter from Dr. Thomas Nasca (CEO for ACGME) to my attention yesterday. I was so impressed by Dr. Nasca's thoughtful response to the report that I decided to scrap the topic planned for November and bring your attention to this document. After reading Dr. Nasca's letter, I wondered what our community was thinking about the IOM report and the ACGME response.

It would be hard to imagine that any physician group would argue against patient safety. The primacy of keeping patients' safe is one of the foundational principles of the social contract that physicians have with the public. After reading Dr. Nasca's letter, I can see that there are many contributing factors to a safe clinical environment. Sometimes these 'competing goods' are in conflict. A well rested resident is a good thing. Fewer staff hand-offs during care is also a good thing. If you haven't read Dr Nasca's letter and you teach residents, I suggest you take the time. I hope you also take the time to share your opinions on this vitally important issue.

http://acgme.org/acWebsite/home/NascaLetterCommunity10_27_09.pdf

SEPTEMBER/OCTOBER SUMMARY

Strong opinions were voiced by our respondents to the question: Are Academic RVU's the Answer to Making Time for Teaching? It appeared that either the respondent was strongly in favor or strongly opposed. Those in favor thought that, although not perfect, academic RVU systems provide a way to "account for and recognize" academic efforts. A few of those opposed, seemed "opposed in principle", not really articulating a rationale. However, a small number cited the problem of reducing a highly complex activity (teaching, advising, mentoring) into an artificial formula. In fact, one reader stated that "going down this "slippery slope" could be likened to "pandering to the bean counters". Whether or not Academic RVU's surface again as an option, we know that there will be strong opinions on both sides.

ARE ACADEMIC RVUs THE ANSWER TO MAKING TIME FOR TEACHING?

The problem of finding time for teaching and having that time “honored” as valuable to the institution has been an ongoing concern for academic medical departments; but perhaps never more than now. Some departments have begun exploring adapting the familiar clinical metric, RVU’s or relative value units as a way to place comparable value on time taken by physicians in their roles as teachers and researchers.

In a 2007 article in J Am Coll Radiol (see link below) the authors state: "Despite the importance of teaching, research, and related activities to the mission of academic medical departments, no useful and widely agreed-on metrics exist with which to assess the value of individual faculty members’ contributions in these areas.

They go on to describe the use of RVUs as a common metric. In their model, all academic activity is quantified and weighted based on "estimates of effort, impact, and value to the department" (Mezrich,R & Nagy, PG. 2007). In the category of teaching, for example, classroom teaching and student feedback are factored into the equation, while clinical teaching is factored into clinical productivity. It is an article well worth reading if you are considering an RVU-based system. Their experience details the complexity of the process and the importance of linking departmental goals to the weighting system

In theory it sounds good, but how do you truly account for time spent preparing new interactive seminars, case-based teaching sessions, facilitating PBL or the development of innovations like online teaching modules. How do you account for time for providing feedback, writing evaluations and mentoring students and residents? Can we deconstruct teaching into RVUs… Should we? What do you think?

For ohiolink users

For citation and abstract

AUGUST 2009 SUMMARY

The concept of introducing or expanding online learning in medical education stimulated a good discussion. Some of our readers described their experience with online learning as boring, painful, and passive, while others described their experiences as interactive, satisfying and effective. How do you account for the disparity of experience and opinion? One reader suggested that the question was phrased too simply. Like most questions in medicine and medical education, the answer usually begins with "it depends". Our readers thought that "it depended" on the purpose of the instruction, the learning style and motivation of the students, the skill of the teacher and the ability of the technology used to create interaction. One reader thought that the generation of the student cohort might also influence the effectiveness of the instruction. Neil, on September 2 (see comments) really did a nice job of addressing the complexity of the question He concluded, as did others, that a blend of online and face-to-face methods may be the best approach. For more information see link below:

http://www.ed.gov/rschstat/eval/tech/evidence-based-practices/finalreport.pdf