Patient safety, work hour regulations, and resident education.

In this issue of Pediatrics, Drolet and coauthors report the opinions of pediatric residency program directors about the 2011 resident workhour restrictions 1 year after implementation: “Resident education, quality of life, continuity of patient care have worsened, with no improvements in numerous areas including fatigue, patient safety, and supervision.” Do these opinions simply represent resistance to change? It is notable that the 2003 restrictions that caused an uproar when implemented are now considered “approved.” So should we take a “this, too, shall pass” attitude? Or do the opinions signal significant issues to be addressed? The past few years have been tumultuous in pediatric education, as programs coped with the 2011 restrictions, new 2013 Accreditation Council for Graduate Medical Education (ACGME) Review Committee for Pediatrics requirements, and, in many programs, the implementation of electronic medical record systems. Also, in many programs, aspects of supervision have changed, including a decrease in the duration of “on service” periods and an increase in the number of hospitalists. It may be difficult to attribute outcomes to individual changes affecting education, but the importance of actually measuring outcomes is clear. The current report provokes at least 4 sets of questions: 1. What is the relationship between patient safety and education? Do efforts to improve the former necessarily damage the latter? What measures should be used to assess outcomes? The failure of the 2003 regulations to improve morbidity and mortality likely disappointed some in the public sector. More sensitive measures specific to resident performance also revealed no change in the overall rate of medication errors and even a slight increase in the rate of ordering errors. A further restriction of intern work hours from 24-hour to 16-hour shifts in an adult ICU resulted in fewer errors by the interns, a demonstration that received considerable attention. Residents and faculty involved in that ICU during this pivotal study were less enthusiastic than the researchers, however. They pointed out that interns may have made fewer mistakes in part because senior residents made more of the decisions. The shift in decision-making from interns to more senior residents, which appears to have occurred after the 2011 regulations as well, may be less an unintended consequence of duty-hour restrictions than an intended one, at least for patient safety. On its face, that should be a good thing for patient safety. Might it also be a good thing for pediatric education, as a crescendo toward a lifetime of independent decision-making? “Progressive responsibility is one of the core tenets of American graduate medical education,” and it seems responsibility is more “progressive” since 2011 than previously. AUTHOR: Kenneth B. Roberts, MD