在論住院醫師值班問題

[李誠民]

美國於2003年經ACGME(Accreditation Concil for Graduate Medical Education)訂下住院醫師值班時數(Duty Hours)每周不可超過80 小時後(當然與紐約州的 Libby Zion law有關—2003年),IOM(Istitute Of Medicine_也附加一些限制;

到2009年有IOM針對住院醫師減少值班時間,是否就增加病患安全與花費提出檢討報告;---由UCLA Stanford大學等專家根據已出版的文獻作統計 分析,------Conclusions:(東部醫學中心的事,五年後交西部醫學院研究)
Implementing the four IOM recommendations would be costly, and their effectiveness is unknown. If highly effective, they could prevent patient harm at reduced or no cost from the societal perspective. However, net costs to teaching hospitals would remain high.(NEJM: Teryl K.Nuckolset.al.:Cost implications od reduced work hours and orkloads for resident physician,May21,2009) 隔沒多久,Aug.27,2009NEJM就有一連串的討論----"Residents' work Hours",其中John Hopkins School of Medicine DR.John D.Rybock 文章---"Residents Duty Hours and Professionalism",我引用來作結論::

......We are required to teach our residents about recognizing fatigue, and this approach would allow us to verify that learning in a supervised setting.
If we fail to make this change to our training system, we will end up with a large number of medical workers, not medical professionals.----

我懂只要多招醫師填補縮短工時空隙即可.我想真正不懂的大概是如何不增加經費又能填補縮短工時空隙?---會有紮實訓練的醫師?,有能力獨立作業?;,尤其外科系,;不增加經費(健保給付)只有台灣才有,請詳讀上篇個人提供文章

請上網查IOM&ACGME官方網站;;僅摘錄部分
Common Program Requirements
Effective: July 1, 2011
Note: The term “resident” in this document refers to both specialty residents and subspecialty
fellows. Once the Common Program Requirements are inserted into each set of specialty and
subspecialty requirements, the terms “resident” and “fellow” will be used respectively.
Introduction
Residency is an essential dimension of the transformation of the medical student to the
independent practitioner along the continuum of medical education. It is physically,
emotionally, and intellectually demanding, and requires longitudinally-concentrated effort
on the part of the resident.
The specialty education of physicians to practice independently is experiential, and
necessarily occurs within the context of the health care delivery system. Developing the
skills, knowledge, and attitudes leading to proficiency in all the domains of clinical
competency requires the resident physician to assume personal responsibility for the
care of individual patients. For the resident, the essential learning activity is interaction
with patients under the guidance and supervision of faculty members who give value,
context, and meaning to those interactions. As residents gain experience and
demonstrate growth in their ability to care for patients, they assume roles that permit
them to exercise those skills with greater independence. This concept—graded and
progressive responsibility—is one of the core tenets of American graduate medical
education. Supervision in the setting of graduate medical education has the goals of
assuring the provision of safe and effective care to the individual patient; assuring each
resident’s development of the skills, knowledge, and attitudes required to enter the
unsupervised practice of medicine; and establishing a foundation for continued
professional growth.I. Institutions
I.A. Sponsoring Institution
One sponsoring institution must assume ultimate responsibility for the program,
as described in the Institutional Requirements, and this responsibility extends to
resident assignments at all participating sites.
The sponsoring institution and the program must ensure that the program
director has sufficient protected time and financial support for his or her
educational and administrative responsibilities to the program.
I.B. Participating Sites
I.B.1. There must be a program letter of agreement (PLA) between the program
and each participating site providing a required assignment. The PLA
must be renewed at least every five years.
Common Program Requirements 2
The PLA should:
I.B.1.a) identify the faculty who will assume both educational and
supervisory responsibilities for residents;
I.B.1.b) specify their responsibilities for teaching, supervision, and formal
evaluation of residents, as specified later in this document;
I.B.1.c) specify the duration and content of the educational experience;
and,
I.B.1.d) state the policies and procedures that will govern resident
education during the assignment.
I.B.2. The program director must submit any additions or deletions of
participating sites routinely providing an educational experience, required
for all residents, of one month full time equivalent (FTE) or more through
the Accreditation Council for Graduate Medical Education (ACGME)
Accreditation Data System (ADS)................
In line with many of the IOM’s recommendations, the new standards require residency programs to:

tailor supervision standards for different levels of training, particularly greater supervision for first-year residents—Intern


1.2010 Duty Hour Standards: Seeing Beyond the Numeric Limits
Ingrid Philibert and Thomas Nasca
Mayo Clin Proc. July 2011 86(7):703; doi:10.4065/mcp.2011.0163
2.Think Broad, Act Lean: Implications of Residency Training and Duty Hour Changes on Health Care Costs
James H. Tabibian
Mayo Clin Proc. July 2011 86(7):703-705; doi:10.4065/mcp.2011.0179
在本期另有四篇討論文章,及三月Myo Clinic Proceeding 也有文章探討,主要是回應IOM研究結果(刊登在NEJM:Aug.27,2009)---哈佛醫學院文,重點摘錄如下:
1. Journalist Sidney Zion(Libby zion 母親,父親為有名律師) brought the issue of resident duty hours to public attention after the death of his 18-year-old daughter, Libby, at a New York hospital in 1984. Although the root cause of her death was really lack of supervision, not excessive duty hours, New York instituted duty hour regulations for residents in 1989, limiting weekly service to 80 hours and shift lengths to 24 hours
2.Public Citizen compared residents' schedules to those of workers in other industries with regulated work hours, such as truck drivers and airline pilots, and in 2002 asked the Occupational Safety and Health Administration (OSHA) to regulate and reduce work hours for resident physicians2. However, a physician is not a truck driver, and a very sick patient is not an 18-wheeler that can be pulled into a rest stop on the expressway. Although OSHA wisely decline Public Citizen's request, regulation was in the air, and resident duty hours legislation was introduced in 2003 by US Senator Jon Corzine and Representative John Conyers.3. These pressures, combined with residents' fears of negative consequences for programs, program directors, and their own careers (in the event of program probation or withdrawal), created powerful disincentives to honest and accurate reporting.
Amid these controversies, in September 2007, at the request of the US Congress and the Agency for Healthcare Research and Quality, the Institute of Medicine (IOM) appointed a committee to synthesize current evidence on medical resident schedules and health care safety and to develop strategies for implementing optimal work schedules to improve safety in health care.4. Public Citizen argued that resident health and well-being were endangered by existing ACGME rules and that OSHA regulations were needed. The American Medical Association, with input and support from both its Medical Student Section and Resident and Fellow Section, wrote OSHA to oppose this petition請願書 and to express strong support of the ACGME and its system of oversight.5 Other member organizations of the ACGME have also written to OSHA, supporting the ACGME's role and arguing that it is impossible to separate duty hours from the overall educational and clinical environment.
5. Other recommendations called for greater supervision of residents, limits on patient caseloads, increased interdisciplinary teamwork, and overlap in schedules during shift changes to reduce errors during hand-offs. The report noted that the major barriers to implementation of these changes were cost ($2.3 billion) and an insufficient health care workforce to substitute for residents. Nonetheless, the report called for action on all recommendations by December 2010.-............
2009 2010 2011 將有許多會議召開,拭目以待吧!
ps:我個人一直認知台灣因民粹而社會價值觀極度扭曲,公共議題似乎沒理性討論空間,至少台灣醫學中心應正視認知住院醫師(實習醫師 甚至總醫師)是受訓者(Trainee),是教學醫院的主要勞力(?)來源,又是權益最易被忽視的一群,所以應重視課程安排,否則怎對得起日後的同儕,認識疲勞(recognize fatigue)不是單純失眠或疲勞症狀介紹,而是建立一套正常申訴管道與保障他的正當權益,不會被醫院壓榨與侵犯等,這是培養醫師基本信仰與價值觀最重要的第一步,醫師養成教育(尤其內 外 婦 兒四大科)不可能不超過,甚至每周80 小時的值班在某些科(多半外 婦產科系)一定是造假的,哪些醫院值班是否合理,醫政處 或醫院評鑑基金會是不可能不知的,醫界都是同儕,可能嗎?用真正輔導 醫師倫理與規範才可能改善,因為台灣健保制度的資源分配與給付就是不合理