Taking sides over taking call

New limits for first-year medical residents meet resistance from pathologists

Earlier this year, an editorial in the Canadian Medical Association Journal posed a delicate question that has been simmering for years: should the professional culture of medicine shift away from long periods on call to preserve patient safety? Fueled by studies hinting at the dangers of sleep deprivation to both physicians and patients, Noni MacDonald, MD, MSc, former dean of medicine at Dalhousie University in Halifax, Nova Scotia, and colleagues argued that the answer should be a definite yes.1

Among many pathologists, however, the debate over finding the right balance between resident education and patient care has centered not on the question of sleep loss and overall work hours but rather on experience and whether first-year residents (PGY1 s) should be taking call at all.

For the Accreditation Council for Graduate Medical Education (ACGME), the answer is no, which concerns many directors of pathology residency programs. Newly issued rules for medical residents, which took effect July 1, 2011, stopped short of the stricter recommendations made by the Institute of Medicine, but nevertheless fundamentally reshaped first-year training schemes. PGY1s are now barred from working any shifts longer than 16 hours and prohibited from taking call until their second year.

Residency Directors Weigh In

The first half of that ruling has been widely criticized by residency directors in internal medicine, general surgery, and pediatrics; in a survey last year, only 14% agreed with the limits.2 For most pathology residency directors, daily and weekly caps on work hours (no more than 80 hours per week, averaged over 4 weeks) are far less of a concern. At East Carolina University in Greenville, North Carolina, for example, the lone resident rotating through cytopathology averages 50 to 60 work hours per week. “I see no possibility that we can violate that rule,” says Heng Hong, MD, PhD, assistant professor of pathology and director of the cytopathology residency program there.

Robert L Low, MD, PhD, associate professor and graduate program director of pathology at the University of Colorado School of Medicine in Denver, Colorado, agrees. “Duty hour limits have never been an issue in pathology,” he says. Dr. Low and other directors are considerably more agitated about the rule barring PGY1s from taking call. “Taking call is not onerous and, in fact, is an invaluable experience for residents,” Dr. Low says.

“The rule that precludes PGY1 residents from participating on call is ill-conceived and disappointing.”

With a bit of difficulty, he says, his department has managed to create a weekend and holiday on-call schedule filled by more senior residents. That kind of reshuffling, however, has led to other challenges. Christine Fuller, MD, residency program director at Virginia Commonwealth University in Richmond, Virginia, contends that the ACGME ban on calls for PGY1s has diminished their sense of responsibility and urgency toward learning and applying knowledge. As a result, the year has been transformed into something “like a glorified senior medical student rotation,” she says. Dr. Fuller says she has also sensed some animosity aimed at incoming residents by more senior residents because of their significant increase in call responsibility.

Another common refrain is that the council has treated all specialties alike, ignoring the distinctions in residents' responsibilities and learning environments. “I can only say that the tendency of the ACGME to treat all specialties as if they were essentially the same as internal medicine is not healthy for residency programs in those other specialties,” says John Sinard, MD, PhD, director of the pathology residency program at Yale- New Haven Medical Center in New Haven, Connecticut.

Pathology residents, Dr. Sinard contends, have less structured schedules than those in other specialties and should be given the opportunity to learn in the way that works best for them. Many pathology residents at Yale, he says, find it more valuable to read about their cases while they study the accompanying slides during work hours. “It is unfortunate that we sometimes have to discourage this practice or even send residents home in order to avoid duty hour issues,” he says.

A Question of Experience

Dr. Fuller has instead questioned the rule's underlying rationale that pathology PGY1s are putting patients at risk because they are inexperienced and not supervised enough while on call. That premise may be true for internal medicine, surgery, and other clinical services, but she considers it much less applicable to pathology due to the specialty's wide variation in how residents acquire learning and experience.

Although pathology residents complete a standardized suite of subspecialty rotations, the exact sequence of those rotations may vary from one institution to another. At Virginia Commonwealth University, for example, residents do a 3- month transfusion medicine rotation during their first year, and then again during their third year. “Transfusion med is a huge part of clinical pathology on-call responsibility,” Dr. Fuller says, “so now we are in the situation where a PGY1 resident taking transfusion medicine is denied the experience of being able to directly apply that knowledge in an on-call setting.”

When call responsibility begins in the second postgraduate year, she says, “there's a high likelihood that residents will be pretty rusty in their transfusion medicine knowledge base.” Those residents might assume more risk in handling patient care issues than if they had been allowed to practice more and have on-call time during their PGY1 year, Dr. Fuller says. “Program directors have scrambled to come up with some innovative ideas on how to at least mimic “on-call” situations for the PGY1s so that they'll hopefully at least try to prepare for real call experience that will come in their second year,” she says.

In response to a request for comment, ACGME CEO ThomasJ. Nasca, MD, noted that the new rules do not preclude first-year residents from working overnight in a hospital. However, he did not address complaints about the first-year ban on taking at-home call and its potential for negative impacts on pathology residents' education and training. As for residency directors, the principal complaints may vary by specialty, but one common concern has been how to fairly mete out responsibility. At the University of Minnesota's internal medicine residency program, for example, adhering to the 16-hour work limit for PGY1s has meant shifting more responsibility for patient care to senior residents, staff, and physician extenders.

A brief publication in Minnesota Medicine last fall described the ensuing implications for graduate education: “This introduces the idea of giving residents progressive responsibility during their training, and it marks a big change, as we traditionally front-loaded responsibility by having first-year residents spend the bulk of their time in the inpatient setting so more senior residents could spend more time doing electives.”3

Canada is likewise struggling with how to implement a consistent and fair set of rules for medical residents and maintain a proper balance between education and patient care. That quandary has been highlighted by this summer's court decision in Quebec Province that limited PGY1 work shifts there to no more than 16 consecutive hours. Even before the decision, the Royal College of Physicians and Surgeons had convened a task force “to forge a pan-Canadian consensus on residents' duty hours that all jurisdictions in our country can use to replace the patchwork quilt of rules, regulations, and conventions that now governs residents' duty hours in Canada.”

Reaching a consensus may require a larger reappraisal of the culture in medicine, says Jason Ford, MD, associate professor of pathology and laboratory medicine at the University of British Columbia in Vancouver. “You can have all of the regulations you want,” he says, “but if the trainees have a culture of competitiveness and obedience, they will do whatever they feel they have to do, whether that's within any kind of duty hour restriction or not.”

BRYN NELSON IS A FREELANCE MEDICAL JOURNALIST.