Five Questions With: Dr. James Arrighi

"Although it is true that hospital budgets are tight, the rules that govern residency programs are relatively insulated from the budgetary pressures."

Dr. James Arrighi is the director of graduate medical education for Lifespan hospitals. He is the chairman of the residency review committee for internal medicine for the Accreditation Council for Graduate Medical Education, a national organization. He recently co-authored an editorial in JAMA about the structuring of residents’ duty hour requirements.

PBN: Are residents getting enough rest?
ARRIGHI:
While asking about the amount of “rest” is a reasonable question, it is important to understand that our major concern is fatigue, which depends on a number of factors, only one of which is the amount of rest or sleep that a person gets. For example, a resident may become quite fatigued, even if well rested previously, in situations of high stress. So, what we really want to achieve in medical education is to teach faculty and trainees how to recognize the symptoms of fatigue in themselves and others and to respond appropriately in order to maintain patient safety and their own effectiveness as a caregiver.

PBN: How has the effort to make residents’ calendars a little saner complicated care in hospitals?
ARRIGHI
: One aspect of the rules that govern resident training programs is the “duty hour” rules. These rules define limits on weekly hours and daily shifts. Restricting hours had some positive effects, such as preventing unreasonable on-call schedules and ensuring that training programs had some basic guidelines across the country. The rules also had some negative unintended consequences, such as increasing hand-offs from one physician to another and creating an atmosphere of trying to get more work done in a shorter period.

PBN: Are budgets tightening at hospitals at the current time when it comes to residencies, and if so does that make it that much harder to create work-life balance for residents – or even just to keep them adequately rested?
ARRIGHI
: Although it is true that hospital budgets are tight, the rules that govern residency programs are relatively insulated from the budgetary pressures. So the hospitals with training programs are bound by the rules to monitor residents’ duty hours and fatigue or they risk losing their accreditation. That said, this situation can place more financial stress on academic medical centers, since sometimes additional personnel (for example, other advanced care providers, administrative staff) have been needed to optimize the educational environment.

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PBN: How often does the typical resident admit to being too tired for duty – and how difficult has it been to create a culture in which a resident can safely do so?
ARRIGHI
: This is perhaps the most important question. As professionals, physicians must have the skill to identify impairment from fatigue and foster a culture to make it acceptable to transition care to another caregiver without any negative perception. This is not always as easy as it sounds. Physicians often develop a tight bond with their patients and have a deep sense of responsibility to them; they want to see their patients’ course through its completion. Stepping away can be difficult, but at times can be the best thing for the patient. Through education and training guidelines, institutions have done much to teach this aspect of professionalism in medicine. At Lifespan, for example, our faculty members are taught to recognize fatigue in trainees, and we foster a culture of honest reporting without any negative stigma. We even will provide sleeping arrangements or transportation for overly fatigued residents.

PBN: How important is varying duty hour requirements for different specialties?
ARRIGHI
: More research needs to be done in this area. At present, one set of duty hour rules applies to all specialties. The intensity of work done on call, however, varies greatly. In some specialties, emergencies may be rare or most issues may be handled over the phone. In other specialties, one must be prepared to do complex procedures at any hour of the night. I think that, in time, we may be able to develop more specialty-specific duty hour guidelines.

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