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Remarks by Carolyn M. Clancy, M.D., Director, Agency for Healthcare Research and Quality (AHRQ)
Institute of Medicine, Washington, DC
December 3, 2007
Good morning. I cannot tell you
how pleased I am to have such a body of experts coming together to find
solutions to one of the preventable causes of errors in health care—the
extended shifts worked by graduate medical trainees in teaching hospitals and
other health care institutions.
As you know, some of our colleagues continue to believe that there is no
correlation between the extended work hours of graduate medical trainees and
quality of care. They say the long hours are good for the continuity of care
and reducing them would put these trainees at risk of missing valuable learning
opportunities. I think we know better.
My family used to ask me about this all of the time. I don't come from a family of doctors, and
they would ask "How do you not make mistakes when you've been up all night?" I hated these questions. I would always talk about adrenaline and
people checking on you and other things, but the truth is that I really didn't
have an answer. It probably had more to
do with prayer and coffee than anything else.
As for the potential impact of these long hours, the research findings
speak for themselves:
- We know that
first-year doctors-in-training who work five extra-long shifts increase
their chances of making a potentially deadly error by 300 percent.
- We know that
first-year graduate medical trainees are more likely to injure themselves
with sharp instruments when they work for 20 hours straight.
- We also know
that these trainees more than double their risk of car crashes when they
drive home after working extended shifts. I have very vivid recollections of seeing people in casts.
Furthermore, we know that despite rules being put in place in 2003 to
govern resident work schedules that the culture and traditions remain very strong. What we need are some levers—maybe even some
financial levers—to make it easier for people to do the right thing.
So, for that reason, my colleagues and I are gratified that Congressmen
John Dingell, Joe Barton, and other members of the House Committee on Energy
and Commerce view this issue with the high level of importance that we think it
The congressional concern gives us an opportunity to make a
difference. Of course, it will up the
We will have to come up with real solutions, because I don't believe Congress
and the public that they represent will have much tolerance for anything less
than some thoughtful recommendations from this group. If we don't give members of Congress some
workable leading-edge solutions, they will come up with their own. I don't think any of us wants to abdicate our
responsibility for dealing with an issue of this magnitude, so I want to be
very specific in explaining what I hope this committee will consider over the
course of your deliberations.
The primary task of this committee will be to focus on four areas:
- Synthesis of
the current evidence base on graduate medical trainees hours and works
schedules and their impact on safety.
and development of strategies, practices, interventions, and tools that
can be used to implement reasonable work hours.
- Analysis of
both the potential benefits and harms of updating work hours and schedules.
- Short- and
long-term recommendations for action by various stakeholders and interim
strategies and policies for implementing these recommendations.
I know that this is a lot of work. But, I think the bottom line is that there must be change. The complacent
era of graduate medical trainees being exposed to extended hours for no good
reason when there is a clear downside is about to come to a close.
The reasons for keeping these traditions going are not rooted in
science. They are based on opinion, traditions, and very strong beliefs which
are perceived rather than actual barriers to change.
At some point, we have to acknowledge the fact that a human being can
work only so long without sleep deprivation becoming a factor. Research shows that we do not do well in
transitions of care, but limiting these transitions by having work hours that
are not compatible with human physiology is not the answer.
It is unsafe and it belies virtually all of the tenets of providing good
health care. How can we profess to
provide the best possible quality when we know we have staff members who are firing
on fewer than all cylinders at levels of sleep deprivation so severe that they
are similar to those of someone who is doing community service for driving
under the influence of alcohol?
The problem exists across health care. AHRQ sponsored an IOM study not long ago that focused on working
conditions for nurses. Their hours, as
well as those of other health care professionals, are also a concern. But in order to have a narrow enough focus, the
scope of this effort is specific to graduate medical trainees.
People in the United
are increasingly worried about their
health care and the research suggests that they should be. We know that poor quality care is an issue
that really must be addressed. The real
issue is much more personal. The real
issue here is how good is my health care?
At this point, I am not sure we have an answer for most
Americans. And I think that with this
committee we have a chance to go beyond providing answers. We can provide solutions.
We are hoping you can
send Congress recommendations that can have an impact on the quality of care
across the Nation.
Thank you very much for being a part of this panel. I am already looking forward to reading your
report next year.
Current as of December 2007