No single hours guideline fits all resident training situations

Regarding "It's not enough just to reduce residents' hours" (Article, Jan. 17): Whereas a significant debate in the profession still exists as to the appropriate duty hours, we must not lose focus on the overall goal. For most interns, the aim of entering a residency program is to obtain the skills and tools to become the best practicing physician he or she possibly can be at graduation.

Of course, it is absurd to lump all fields of medicine into a single guideline for duty hours. It might make the ACGME feel better, but the ground situation is obviously different.

Surgical fields must be provided the liberty to handle themselves. For example, a recent study in the Laryngoscope documents that during the performance of simulated endoscopic sinus surgery, there was no diminution of performance before or after 24-hour call period.

In internal medicine, family medicine, pediatrics and ob-gyn programs, we cannot discount the effect of patient load -- and not simply total hours -- on performance. Also, effectiveness and efficiency should both be measured simultaneously. Effectiveness can be regarded as "doing the right thing," whereas efficiency is "doing the things right." There is much difference between the two concepts, and we should attempt to aim for both.

In summary, what really counts is whether our residents are trained to be both efficient and effective managers in patient care, especially in a managed care era where they will be frequently burdened with patient load as private practitioners in a litigious society. Can we truly be held to the highest ethical standards by our patients when we did not train at the most intense level?

Rahul Gupta, MD, Huntsville, Ala.

Note: This item originally appeared at http://www.ama-assn.org/amednews/2005/02/14/edlt0214.htm.