Opinion
Editorials represent the opinions of the authors and JAMA and not those of the American Medical Association
EDITORIAL
Certifying the Good Physician A Work in Progress Thomas H. Lee, MD, MSc
In recent decades, two important but distinct questions relevant to the evaluation of physicians have become increasingly intertwined. The first of these questions is “Who is good enough?” The second is “Who is trying to improve?” The latter issue has become critical Related articles pages 2348 due to the accelerating rate of and 2358 medical progress and the growing complexity of health care delivery. In the current era, good physicians are defined by more than passing difficult tests early in their career; good physicians are individuals who are also working to become better—actively engaged in keeping up with medical progress and measurably trying to improve the care they provide. Both of these questions are complex, and difficult to answer with certainty or efficiency. Nevertheless, both questions must be addressed, and decisions must be made based on the data that result from evaluation, imperfect though the data might be. After all, patients need to choose physicians, health care organizations need to decide whom to hire, and physicians need insight into their own strengths and weaknesses. Moreover, as a profession, medicine has an inherent responsibility to assess various aspects of what it means to be a good physician. For most of the last century, board certification has been the means by which professional societies, the public, and health care institutions identified physicians who met peerestablished standards. The nature of these standards and the requirements for maintaining board certification are now in flux,1 as has occurred every decade since 1990. Coming at a time of turmoil for physicians, these changes have been far from welcome2 and have elicited a firestorm of criticism and debate. Two studies in this issue of JAMA provide much needed data to inform these discussions,3,4 which all too often have been data-free. A superficial reading of these reports might suggest that requirements for Maintenance of Certification (MOC) introduced in 1990 have had no positive effect on care. A bold extrapolation of these data might lead to the conclusion that changes to MOC introduced in 2006 and in 2014 are therefore likely to be similarly ineffective, and should be unwound. Another assessment might be that the effect of MOC is unknown at best and that changes to its structure must be undertaken with caution and sensitivity to their effect on physicians’ professional lives. After all, the most fundamental principle of medicine is “First, do no harm.” That said, if professional societies and boards try nothing new to improve qual2340
ity and efficiency, other agencies (government, payers, and employers) are likely to attempt to fill the gap, with consequences that might be more challenging for clinicians and patient care. Therefore, physicians should think of MOC as an imperfect process that must be made better, and ask what lessons these data provide about improving it. The study by Gray and colleagues3 is from the American Board of Internal Medicine (ABIM), the largest of the US specialty boards and the one under the fiercest criticism for its recent changes to MOC. With coauthors from other institutions, these investigators compared rates of ambulatory care– sensitive hospitalizations (ACSHs) for Medicare patients of 2 groups of general internists—974 general internists who had received time-unlimited board certification in 1989 (MOCgrandfathered), and 956 general internists who received time-limited certification just 2 years later (MOC-required), after the ABIM introduced its requirement for MOC. Ambulatory care–sensitive hospitalizations are hospitalizations triggered by conditions (eg, diabetes and asthma) thought to be potentially preventable through better access to and quality of outpatient care. The outcomes and cost data were derived from Medicare data from patients for whom these general internists delivered a significant amount (plurality but not necessarily the majority) of their care from 1999 to 2005. Thus, in this relatively stable “laboratory,” the researchers could evaluate patterns of care before and after the year 2000, when the 956 MOCrequired general internists had to undergo recertification examination. The Medicare beneficiaries attributed to the MOCrequired general internists had 2% lower total costs, but no significant difference was found for ACSH rates between the 2 groups of physicians. These data are by far the best study of patient outcomes associated with time-limited board certification. However, the outcome measure (ACSH) was designed to assess access to primary care in populations, not the quality of care delivered by individual physicians. The rigorous study design meant that the analysis was based on only about 80 patients from each physician’s panel. These physicians accounted for a minority of the patients’ total care and total costs. In this context, if the null hypothesis had been rejected, and a statistically significant improvement in this particular quality metric had been detected after just 1 recertification examination, such findings would have been remarkable and would have demanded further study and replication, as do the results of this study. As difficult as this study may have been to perform, it should be replicated with successive cohorts of
JAMA December 10, 2014 Volume 312, Number 22
Copyright 2014 American Medical Association. All rights reserved.
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Editorial Opinion
physicians and patients, even if none of the subsequent groups of certified physicians will be as comparable with the 1989 group. The finding of a 2% cost reduction associated with timelimited certification is a potentially positive surprise. This result should not be dismissed as a statistical fluke, because prior data show that older physicians tend to generate lower total health care spending than younger and presumably lessexperienced colleagues. 5 Thus, this association of timelimited certification with lower costs was in the opposite direction from what would have been anticipated, increasing the chances that board recertification might have actually helped physicians become more efficient. The 2% reduction in spending is as large or larger than the savings recorded by the Medicare accountable care organizations in their first 2 years, so further study to determine if this finding is real and reproducible is critical. The report by Hayes and colleagues4 from the Veterans Health Administration (VA) analyzed standard Healthcare Effectiveness Data and Information Set (HEDIS)–type process measures for the primary care panels of 105 internists at 4 VA medical centers. The main findings from this smaller study were that there were no differences in these process measures between the 71 physicians with time-limited ABIM certification compared with the 34 physicians with timeunlimited certification. However, the most important finding from this study was that all of the rates were better— much better—than those recorded by the US health care system overall.6 The VA has absorbed much well-deserved criticism over the last year, but the VA has built systems that made many aspects of its care as good or better than the rest of the country. The study by Hayes et al showed that having an effective team focused on diabetes care was probably more important than having a recertified physician for achieving hemoglobin A1c levels less than 9% (79% in the study by Hayes et al vs about 71% in National Committee for Quality Assurance data for the United States6) The same was true for all of the quality metrics evaluated in this study. The findings in this study provide a reminder that health care today has become team-based. Many clinicians are involved in delivering routine care, and how well those clinicians integrate their efforts is the dominant determinant of patient outcomes, safety, and efficiency. For measuring and improving outcomes and costs, the individual physician is not the correct unit of analysis. Physicians have enormous roles in the course of individual patients every day, but the function (or dysfunction) of the systems that surround physicians are what move the needle for large patient populations on the types of metrics used in these studies. This makes the assessment of individual physicians an even more difficult task. If health care really is team-based, does certification and MOC for individual physicians matter? Or does MOC consume so much time, resources, and emotional energy that these processes should be dismantled? Certification and MOC clearly must evolve and improve, but they should not go away. Health care teams need good team
members, and thus need to know who is qualified for the key roles. Most organizations are using board certification as a criterion for deciding whom they will consider for employment, and even though board certification may not represent the pinnacle of achievement it hoped for, it has become a basic criterion for getting and keeping a job. Physicians are the best option for defining those criteria, and must be directly involved in improving the credentialing and MOC processes, rather than run the risk of abdicating this responsibility to others. However, defining the floor of what is minimally acceptable is not enough for a profession that accepts responsibility for self-regulation, particularly for a profession in which the body of knowledge and other demands are expanding and changing so rapidly. It is not even enough to say whose knowledge is sufficient today. The profession must determine who is likely to know enough next month, next year, and the year after that—and how effective physicians are in translating that knowledge into better care. In short, the profession has to help and encourage its members to adopt learning and improvement as core competencies. Appreciation of this imperative is why time-limited certification was implemented by the ABIM in 1990, and why further changes have been introduced in each decade since. Early in the 2000s, it became clear that medicine was moving so rapidly that testing physicians every 10 years was not enough to ensure that they would stay up to date, so the ABIM and other boards moved to more continuous processes for assessing competence. As of 2006, physicians needing or wanting recertification had to complete self-evaluation modules for practice performance, requiring chart review and surveys of patients with selected conditions. This evolution of MOC from a test-per-decade program to continuous monitoring and improvement program precipitated criticisms about the administrative and financial burdens, and the lack of evidence for beneficial effects of MOC on care. That criticism was somewhat muted because older physicians who had time-unlimited board certifications only had to undergo MOC requirements if they volunteered. However, more recent changes have led to lawsuits, petitions, and the organization of groups seeking repeal and reform of MOC. Among the most controversial changes are the ABIM’s requirements for more frequent and widespread participation in activities to assess medical knowledge in practice. The ABIM publishes on its website whether physicians are certified and whether they are “meeting Maintenance of Certification requirements”—even if their certification is time-unlimited. Although it is currently unclear what consequences for physicians may flow from whether they are classified as meeting MOC requirements, this change has led to intense examination of the nature of MOC and the organizations that oversee it. Physicians have difficult jobs, and almost every aspect of those jobs is becoming more complex and feels uncertain—so it is perhaps inevitable that the 2 studies in this issue of JAMA will add fuel to the concerns and anger of some physicians who are critics of the MOC process. Nevertheless, few of these critics argue against the need for some structure to help and encourage physicians to stay up to date and improve their ac-
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JAMA December 10, 2014 Volume 312, Number 22
Copyright 2014 American Medical Association. All rights reserved.
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2341
Opinion Editorial
tual skills. They are pushing for thoughtful integration of the MOC program into their busy professional lives, so that the expense and time commitment are reasonable. An optimistic assessment is that medicine in the United States is actually moving in that direction—away from relying on grueling tests once per decade, toward creating systems that give physicians feedback on how they are performing and how they can improve based on the actual care they deliver. The transition to this type of data-driven assessment is difficult, and will remain challenging until information technology improves, along with the way physicians work with that technology and with their clinical colleagues. Professional societies and physicians have a duty to criticize the problems with MOC, but also to participate actively in improving it. They must guard against the temptation to “dumb down” measures to appease angry colleagues, and thus
run the risk of ending up with an MOC system that simply does not accomplish the task at hand, a commitment to lifelong learning. They should recognize the difficulty of creating what physicians want—a system that evaluates them based on what they do, but does not disrupt them as it does so. In sum, physicians should work constructively to help MOC improve, much as physicians should work continuously to improve how they collaborate with colleagues and with patients. In addition, physicians must make the commitment to lifelong, meaningful learning to ensure that their knowledge and skills remain current and relevant. Patients would be disappointed by anything less. The medical profession may never fully understand the effect of MOC, but that does not mean that physicians should give up or stop trying to make it better. The MOC program is a work in progress, as are all good physicians.
ARTICLE INFORMATION
REFERENCES
Author Affiliations: Press Ganey, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; Harvard School of Public Health, Boston, Massachusetts.
1. Baron RJ, Johnson D. The American Board of Internal Medicine. Ann Intern Med. 2014;161(3):221223.
Corresponding Author: Thomas H. Lee, MD, MSc, Press Ganey, 401 Edgewater Place, Suite 500, Wakefield, MA 01880 (thomas.lee@pressganey .com). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Lee reports being chief medical officer for Press Ganey and has time-unlimited board certification from the ABIM.
2. Centor RM, Fleming DA, Moyer DV. Maintenance of Certification. Ann Intern Med. 2014;161(3):226-227. 3. Gray BM, Vandergrift JL, Johnston MM, et al. Association between imposition of a Maintenance of Certification requirement and ambulatory care–sensitive hospitalizations and health care costs. JAMA. doi:10.1001/jama.2014.12716. 4. Hayes J, Jackson JL, McNutt GM, Hertz BJ, Ryan JJ, Pawlikowski SA. Association between physician
time-unlimited vs time-limited internal medicine board certification and ambulatory patient care quality. JAMA. doi:10.1001/jama.2014.13992. 5. Mehrotra A, Reid RO, Adams JL, Friedberg MW, McGlynn EA, Hussey PS. Physicians with the least experience have higher cost profiles than do physicians with the most experience. Health Aff (Millwood). 2012;31(11):2453-2463. 6. National Committee for Quality Assurance. Improving quality and patient experience. http: //www.ncqa.org/Portals/0/Newsroom/SOHC/2013 /SOHC-web_version_report.pdf. September 28, 2014.
Duty Hour Requirements Time for a New Approach? James A. Arrighi, MD; James C. Hebert, MD
Few issues have engendered more passionate debate in the graduate medical education community in the last decade than the Accreditation Council for Graduate Medical Education (ACGME) duty hour program requirements. The premise of Related articles pages 2364 work hour restrictions in a and 2374 profession in which errors may result in harm to the public makes intuitive sense, as does the premise that sleep deprivation detracts from an individual’s overall well-being and ability to learn. Why, then, does the debate about duty hour requirements continue? There are several potential reasons. First, in the US system of care and medical education, the primary mode of resident and fellow education is learning while providing service under graded supervision. This allows residents and fellows to develop the skills necessary to ultimately practice without supervision while providing a significant role in continuity of care. Although this system has served well for almost a cen2342
tury, the time needed for residents to master the exponential growth of knowledge and technological advances has increased substantially over the past 2 to 3 decades. The dual goals of duty hour requirements to optimize patient safety and to preserve an optimal learning environment are often at odds. Second, the number of hours worked by residents represents only one variable among many in a very complex system of health care delivery, all of which may affect patient safety and outcomes. The focus on work hours may be because they are the most easily measured variable. However, work hours do not equate with workload. Restriction of work hours in the absence of other educational reforms may result in compression of workload, potentially increasing residents’ stress. Additionally, the majority of patients in the United States who are hospitalized are not cared for by residents. Third, the same duty hour requirements have been applied to all specialties of medicine and do not recognize potential differences among specialties. For example, a resident in radiation oncology functions primarily in an outpatient en-
JAMA December 10, 2014 Volume 312, Number 22
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Purdue University User on 05/20/2015
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Editorials represent the opinions of the authors and JAMA and not those of the American Medical Association
EDITORIAL
Certifying the Good Physician A Work in Progress Thomas H. Lee, MD, MSc
In recent decades, two important but distinct questions relevant to the evaluation of physicians have become increasingly intertwined. The first of these questions is “Who is good enough?” The second is “Who is trying to improve?” The latter issue has become critical Related articles pages 2348 due to the accelerating rate of and 2358 medical progress and the growing complexity of health care delivery. In the current era, good physicians are defined by more than passing difficult tests early in their career; good physicians are individuals who are also working to become better—actively engaged in keeping up with medical progress and measurably trying to improve the care they provide. Both of these questions are complex, and difficult to answer with certainty or efficiency. Nevertheless, both questions must be addressed, and decisions must be made based on the data that result from evaluation, imperfect though the data might be. After all, patients need to choose physicians, health care organizations need to decide whom to hire, and physicians need insight into their own strengths and weaknesses. Moreover, as a profession, medicine has an inherent responsibility to assess various aspects of what it means to be a good physician. For most of the last century, board certification has been the means by which professional societies, the public, and health care institutions identified physicians who met peerestablished standards. The nature of these standards and the requirements for maintaining board certification are now in flux,1 as has occurred every decade since 1990. Coming at a time of turmoil for physicians, these changes have been far from welcome2 and have elicited a firestorm of criticism and debate. Two studies in this issue of JAMA provide much needed data to inform these discussions,3,4 which all too often have been data-free. A superficial reading of these reports might suggest that requirements for Maintenance of Certification (MOC) introduced in 1990 have had no positive effect on care. A bold extrapolation of these data might lead to the conclusion that changes to MOC introduced in 2006 and in 2014 are therefore likely to be similarly ineffective, and should be unwound. Another assessment might be that the effect of MOC is unknown at best and that changes to its structure must be undertaken with caution and sensitivity to their effect on physicians’ professional lives. After all, the most fundamental principle of medicine is “First, do no harm.” That said, if professional societies and boards try nothing new to improve qual2340
ity and efficiency, other agencies (government, payers, and employers) are likely to attempt to fill the gap, with consequences that might be more challenging for clinicians and patient care. Therefore, physicians should think of MOC as an imperfect process that must be made better, and ask what lessons these data provide about improving it. The study by Gray and colleagues3 is from the American Board of Internal Medicine (ABIM), the largest of the US specialty boards and the one under the fiercest criticism for its recent changes to MOC. With coauthors from other institutions, these investigators compared rates of ambulatory care– sensitive hospitalizations (ACSHs) for Medicare patients of 2 groups of general internists—974 general internists who had received time-unlimited board certification in 1989 (MOCgrandfathered), and 956 general internists who received time-limited certification just 2 years later (MOC-required), after the ABIM introduced its requirement for MOC. Ambulatory care–sensitive hospitalizations are hospitalizations triggered by conditions (eg, diabetes and asthma) thought to be potentially preventable through better access to and quality of outpatient care. The outcomes and cost data were derived from Medicare data from patients for whom these general internists delivered a significant amount (plurality but not necessarily the majority) of their care from 1999 to 2005. Thus, in this relatively stable “laboratory,” the researchers could evaluate patterns of care before and after the year 2000, when the 956 MOCrequired general internists had to undergo recertification examination. The Medicare beneficiaries attributed to the MOCrequired general internists had 2% lower total costs, but no significant difference was found for ACSH rates between the 2 groups of physicians. These data are by far the best study of patient outcomes associated with time-limited board certification. However, the outcome measure (ACSH) was designed to assess access to primary care in populations, not the quality of care delivered by individual physicians. The rigorous study design meant that the analysis was based on only about 80 patients from each physician’s panel. These physicians accounted for a minority of the patients’ total care and total costs. In this context, if the null hypothesis had been rejected, and a statistically significant improvement in this particular quality metric had been detected after just 1 recertification examination, such findings would have been remarkable and would have demanded further study and replication, as do the results of this study. As difficult as this study may have been to perform, it should be replicated with successive cohorts of
JAMA December 10, 2014 Volume 312, Number 22
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Purdue University User on 05/20/2015
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Editorial Opinion
physicians and patients, even if none of the subsequent groups of certified physicians will be as comparable with the 1989 group. The finding of a 2% cost reduction associated with timelimited certification is a potentially positive surprise. This result should not be dismissed as a statistical fluke, because prior data show that older physicians tend to generate lower total health care spending than younger and presumably lessexperienced colleagues. 5 Thus, this association of timelimited certification with lower costs was in the opposite direction from what would have been anticipated, increasing the chances that board recertification might have actually helped physicians become more efficient. The 2% reduction in spending is as large or larger than the savings recorded by the Medicare accountable care organizations in their first 2 years, so further study to determine if this finding is real and reproducible is critical. The report by Hayes and colleagues4 from the Veterans Health Administration (VA) analyzed standard Healthcare Effectiveness Data and Information Set (HEDIS)–type process measures for the primary care panels of 105 internists at 4 VA medical centers. The main findings from this smaller study were that there were no differences in these process measures between the 71 physicians with time-limited ABIM certification compared with the 34 physicians with timeunlimited certification. However, the most important finding from this study was that all of the rates were better— much better—than those recorded by the US health care system overall.6 The VA has absorbed much well-deserved criticism over the last year, but the VA has built systems that made many aspects of its care as good or better than the rest of the country. The study by Hayes et al showed that having an effective team focused on diabetes care was probably more important than having a recertified physician for achieving hemoglobin A1c levels less than 9% (79% in the study by Hayes et al vs about 71% in National Committee for Quality Assurance data for the United States6) The same was true for all of the quality metrics evaluated in this study. The findings in this study provide a reminder that health care today has become team-based. Many clinicians are involved in delivering routine care, and how well those clinicians integrate their efforts is the dominant determinant of patient outcomes, safety, and efficiency. For measuring and improving outcomes and costs, the individual physician is not the correct unit of analysis. Physicians have enormous roles in the course of individual patients every day, but the function (or dysfunction) of the systems that surround physicians are what move the needle for large patient populations on the types of metrics used in these studies. This makes the assessment of individual physicians an even more difficult task. If health care really is team-based, does certification and MOC for individual physicians matter? Or does MOC consume so much time, resources, and emotional energy that these processes should be dismantled? Certification and MOC clearly must evolve and improve, but they should not go away. Health care teams need good team
members, and thus need to know who is qualified for the key roles. Most organizations are using board certification as a criterion for deciding whom they will consider for employment, and even though board certification may not represent the pinnacle of achievement it hoped for, it has become a basic criterion for getting and keeping a job. Physicians are the best option for defining those criteria, and must be directly involved in improving the credentialing and MOC processes, rather than run the risk of abdicating this responsibility to others. However, defining the floor of what is minimally acceptable is not enough for a profession that accepts responsibility for self-regulation, particularly for a profession in which the body of knowledge and other demands are expanding and changing so rapidly. It is not even enough to say whose knowledge is sufficient today. The profession must determine who is likely to know enough next month, next year, and the year after that—and how effective physicians are in translating that knowledge into better care. In short, the profession has to help and encourage its members to adopt learning and improvement as core competencies. Appreciation of this imperative is why time-limited certification was implemented by the ABIM in 1990, and why further changes have been introduced in each decade since. Early in the 2000s, it became clear that medicine was moving so rapidly that testing physicians every 10 years was not enough to ensure that they would stay up to date, so the ABIM and other boards moved to more continuous processes for assessing competence. As of 2006, physicians needing or wanting recertification had to complete self-evaluation modules for practice performance, requiring chart review and surveys of patients with selected conditions. This evolution of MOC from a test-per-decade program to continuous monitoring and improvement program precipitated criticisms about the administrative and financial burdens, and the lack of evidence for beneficial effects of MOC on care. That criticism was somewhat muted because older physicians who had time-unlimited board certifications only had to undergo MOC requirements if they volunteered. However, more recent changes have led to lawsuits, petitions, and the organization of groups seeking repeal and reform of MOC. Among the most controversial changes are the ABIM’s requirements for more frequent and widespread participation in activities to assess medical knowledge in practice. The ABIM publishes on its website whether physicians are certified and whether they are “meeting Maintenance of Certification requirements”—even if their certification is time-unlimited. Although it is currently unclear what consequences for physicians may flow from whether they are classified as meeting MOC requirements, this change has led to intense examination of the nature of MOC and the organizations that oversee it. Physicians have difficult jobs, and almost every aspect of those jobs is becoming more complex and feels uncertain—so it is perhaps inevitable that the 2 studies in this issue of JAMA will add fuel to the concerns and anger of some physicians who are critics of the MOC process. Nevertheless, few of these critics argue against the need for some structure to help and encourage physicians to stay up to date and improve their ac-
jama.com
JAMA December 10, 2014 Volume 312, Number 22
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Purdue University User on 05/20/2015
2341
Opinion Editorial
tual skills. They are pushing for thoughtful integration of the MOC program into their busy professional lives, so that the expense and time commitment are reasonable. An optimistic assessment is that medicine in the United States is actually moving in that direction—away from relying on grueling tests once per decade, toward creating systems that give physicians feedback on how they are performing and how they can improve based on the actual care they deliver. The transition to this type of data-driven assessment is difficult, and will remain challenging until information technology improves, along with the way physicians work with that technology and with their clinical colleagues. Professional societies and physicians have a duty to criticize the problems with MOC, but also to participate actively in improving it. They must guard against the temptation to “dumb down” measures to appease angry colleagues, and thus
run the risk of ending up with an MOC system that simply does not accomplish the task at hand, a commitment to lifelong learning. They should recognize the difficulty of creating what physicians want—a system that evaluates them based on what they do, but does not disrupt them as it does so. In sum, physicians should work constructively to help MOC improve, much as physicians should work continuously to improve how they collaborate with colleagues and with patients. In addition, physicians must make the commitment to lifelong, meaningful learning to ensure that their knowledge and skills remain current and relevant. Patients would be disappointed by anything less. The medical profession may never fully understand the effect of MOC, but that does not mean that physicians should give up or stop trying to make it better. The MOC program is a work in progress, as are all good physicians.
ARTICLE INFORMATION
REFERENCES
Author Affiliations: Press Ganey, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; Harvard School of Public Health, Boston, Massachusetts.
1. Baron RJ, Johnson D. The American Board of Internal Medicine. Ann Intern Med. 2014;161(3):221223.
Corresponding Author: Thomas H. Lee, MD, MSc, Press Ganey, 401 Edgewater Place, Suite 500, Wakefield, MA 01880 (thomas.lee@pressganey .com). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Lee reports being chief medical officer for Press Ganey and has time-unlimited board certification from the ABIM.
2. Centor RM, Fleming DA, Moyer DV. Maintenance of Certification. Ann Intern Med. 2014;161(3):226-227. 3. Gray BM, Vandergrift JL, Johnston MM, et al. Association between imposition of a Maintenance of Certification requirement and ambulatory care–sensitive hospitalizations and health care costs. JAMA. doi:10.1001/jama.2014.12716. 4. Hayes J, Jackson JL, McNutt GM, Hertz BJ, Ryan JJ, Pawlikowski SA. Association between physician
time-unlimited vs time-limited internal medicine board certification and ambulatory patient care quality. JAMA. doi:10.1001/jama.2014.13992. 5. Mehrotra A, Reid RO, Adams JL, Friedberg MW, McGlynn EA, Hussey PS. Physicians with the least experience have higher cost profiles than do physicians with the most experience. Health Aff (Millwood). 2012;31(11):2453-2463. 6. National Committee for Quality Assurance. Improving quality and patient experience. http: //www.ncqa.org/Portals/0/Newsroom/SOHC/2013 /SOHC-web_version_report.pdf. September 28, 2014.
Duty Hour Requirements Time for a New Approach? James A. Arrighi, MD; James C. Hebert, MD
Few issues have engendered more passionate debate in the graduate medical education community in the last decade than the Accreditation Council for Graduate Medical Education (ACGME) duty hour program requirements. The premise of Related articles pages 2364 work hour restrictions in a and 2374 profession in which errors may result in harm to the public makes intuitive sense, as does the premise that sleep deprivation detracts from an individual’s overall well-being and ability to learn. Why, then, does the debate about duty hour requirements continue? There are several potential reasons. First, in the US system of care and medical education, the primary mode of resident and fellow education is learning while providing service under graded supervision. This allows residents and fellows to develop the skills necessary to ultimately practice without supervision while providing a significant role in continuity of care. Although this system has served well for almost a cen2342
tury, the time needed for residents to master the exponential growth of knowledge and technological advances has increased substantially over the past 2 to 3 decades. The dual goals of duty hour requirements to optimize patient safety and to preserve an optimal learning environment are often at odds. Second, the number of hours worked by residents represents only one variable among many in a very complex system of health care delivery, all of which may affect patient safety and outcomes. The focus on work hours may be because they are the most easily measured variable. However, work hours do not equate with workload. Restriction of work hours in the absence of other educational reforms may result in compression of workload, potentially increasing residents’ stress. Additionally, the majority of patients in the United States who are hospitalized are not cared for by residents. Third, the same duty hour requirements have been applied to all specialties of medicine and do not recognize potential differences among specialties. For example, a resident in radiation oncology functions primarily in an outpatient en-
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Copyright 2014 American Medical Association. All rights reserved.
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![[Good work].](/assets/img/hold.png)
