More than a century of American medical history was turned on its ear last week by the announcement that the groups that accredit medical residencies will unify their standards. Don’t be too hard on yourself if you failed to understand the significance (or notice at all).
But this should be viewed as good news across the land. As someone who trains doctors from both ‘traditions,’ I certainly welcome a more level playing field.
First, a little background:
Osteopathic physicians (those with a D.O., or Doctor of Osteopathy degree) have a history dating back to the 1800s. They comprise slightly more than 10% of practicing doctors in the United States. Currently, there are 35 osteopathic medical schools, compared with 135 ‘allopathic’ institutions, the kind that confer the M.D. (Doctor of Medicine) degree.
Though historically the two educational paths varied in principles and practice, there aren’t many remaining differences. Both disciplines now use biomedical science as their core.
Originally, osteopathy relied on manipulation of bones and joints to diagnose and treat illness.
This tradition, known as Osteopathic Manipulative Treatment (OMT), lives on in the osteopathic curriculum, though it’s now mostly used as an adjunct for treatment of chronic musculoskeletal conditions. Today, most D.O.s leave OMT behind after they finish their training.
Last year, Public Citizen and other groups filed a petition – the second in 10 years – calling on the Occupational Safety and Health Administration (OSHA) to take over responsibility for enforcing medical resident work hours from the Accreditation Council for Graduate Medical Education (ACGME). This past September, the Obama administration denied our groups’ petition on the grounds that the ACGME is the appropriate entity to handle the issue, an identical argument to one put forward by the Bush administration nine years earlier to justify the denial of our first petition.
Both petitions were filed as a result of the long-standing failure of the ACGME to adequately protect residents from the proven deleterious effects of long work hours. Six years after the ACGME implemented the first limits on resident work hours in 2003, the Institute of Medicine (IOM) concluded an exhaustive 12-month review examining the existing system of medical training and the evidence regarding fatigue, resident physicians, and patient safety. The IOM concluded that the 2003 ACGME rules were not adequately protective and that major changes were needed, including a limit of 16 hours in a row for all resident work shifts.
In response, the ACGME updated its guidelines in 2010, but unfortunately, the new rules failed to incorporate the majority of the IOM’s recommendations. The rules limited medical interns ― first-year residents ― to 16-hour shifts but inexplicably allowed all other residents to continue to work up to 28 hours straight. There is no biological rationale to support the notion that residents suddenly become able to withstand the adverse effects of extended shifts upon completing their first year of residency. In addition, the new rules, in permitting averaging over several weeks to achieve the 80-hour weekly limit, continued the practice of allowing residents to work 100 or more hours in certain weeks.
When I completed my overnight shift and left the Medical ICU the morning of July 1, I raised my arms victoriously. I uttered, “Finally, internship is done!” I may have been one of the last to speak such words.
As of July 1, 2011, intern year forever changed. In the world of medicine the first year of residency, or intern year, is when doctors earn their stripes. Traditionally it is the most demanding year in a decade-long quest to become a practicing physician. But this year, the Accreditation Council of Graduate Medical Education (ACGME) mandated that interns can no longer work more than 16 hours straight, and must have 10 hours off between shifts. Second- and third-year residents can still work 28-hour shifts, but no more 30-hour shifts for interns.
To the outsider, this may seem like a common sense change that would only improve patient safety. Within the medical field, however, this change is arguably the most controversial in the history of medical education.
Advocates believe these duty-hour modifications will decrease medical errors and improve unacceptable working conditions for residents. ACGME officials still believe that residents should be able to handle the vigorous hours and workload, but believe launching the least experienced physicians — new interns — into those demanding conditions just days after medical school is inappropriate and unsafe. As well, the general public generally favors the new changes.