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Commentary on "survey of internal medicine physicians trained in three different eras: reflections on duty-hour reform".

In this issue of the Southern Medical Journal, Burton and colleagues examine physician attitudes toward duty-hour reform at their institution. This topic has received strong physician response from all generations since 2003 when the Accreditation Council for Graduate Medical Education implemented work hour restrictions. This study by Burton and colleagues adds to the literature that demonstrates change does not come easily in a portion of the physician community. The authors surveyed physicians from three discrete training eras with the intent to capture awide spectrum of perceptions regarding dutyhour reform. The study suggests that among respondents, the older generation of academic physicians believes duty-hour reform may cause residents to be less prepared for future careers and focus attention on patient safety. Previous studies on this topic were challenged for their study design, validity, and lack of generalizability. Although this study shares some of the same limitations, we applaud the authors’ effort to explore generational attitudes toward work-hour reform. Appropriately, the authors caution that this small, singlesite survey is not sufficient to draw any firm conclusions; however, the article can serve as an important role as provocateur by providing us an opportunity to thoughtfully explore an issue that resonates with every physician and that should concern every patient. The argument for or against duty-hour restrictions can be framed in terms of the patient (safety, quality of care, and continuity of care), the resident (well-being, competency, and preparedness), and the healthcare system at large (staff shortages, economic costs). Each deserves and it is hoped will receive attention in a thoughtful, well-designed, long-term evaluation. Current reforms embraced by other industries with similar goals of quality improvement, effective training, and public safety could affect decisions in medicine. For example, during the past 2 decades, the National Transportation Safety Board has issued safety recommendations to address impairments caused by fatigue of shortand long-haul truck drivers in an effort to improve public safety. In January 2014, the Federal Aviation Administration adopted new rules to limit the number of consecutive flight hours for commercial airline pilots to ensure public safety in travel. These decisions were based on years of accumulated evidence demonstrating a correlation of fatigue, accidents, or poor judgment in awide variety of industries. The airline industry understands that attempting to generate/complete the same amount of work in less time is not the solution, and major airlines have announced they will increase the number of pilots and other staff to ensure safe operations. The voluminous data in the peer-reviewed literature describing how fatigue affects judgment, concentration, decision making, and other complex tasks are not disputed by any other occupation. The physician community, however, continues to argue for an exception for medical trainees and attending physicians, often turning to various proxies such as concern for patient safety, to bolster an argument not supported by evidence but by tradition. The survey by Burton and colleagues demonstrates a generational reluctance to challenge the existing medical training model. This reluctance may be a result of the medical community’s cultural resistance to change, uncertainty about how best to prepare residents for an evolving healthcare system, and concern about economic impact. The results from this survey may reflect a fundamental limitation of physicians trained (and remaining) in the traditional academic model because many lack the wide lens needed to view their profession and advocate for creative solutions. Although concerns about transitions of patient care and quality of care are worth investigating, researchers typically examine potential consequences from the reduction of duty hours without concomitant changes in resident or attending workload or an adaptive reengineering of the residency program. As for the claim that duty-hour reform reduces resident competency from decreased inpatient encounters and procedural experiences, these claims come without significant study support. Indeed, one study found that intern Invited Commentary