Perspective: ten thousand hours to patient safety, sooner or later

A call by the Institute of Medicine to advance the cause of patient safety catalyzed the current focus on duty hours limits during resident education. Unrelated benefits to resident education have accrued from those efforts, but, despite rigorous study of the issue, there is little evidence of a positive impact on patient safety resulting from trainee duty hours adjustments. Moreover, the discussion has become worrisomely myopic in its singular preoccupation with the impact of postgraduate medical education duty hours on safe patient care. The author argues that patient safety efforts should focus instead on the three essential elements of capacity, of which a discussion of duty hours and fatigue are an important part, commitment, and competence. Commitment requires altruism and professionalism, which are discouraged by a shift-work orientation. Competence is essential for safe patient care; as duty hours are constricted in the name of reducing fatigue-related medical error, it must be remembered that a certain amount of time is required to both acquire a knowledge base and attain proficiency in needed technical skills. Until a competency-based educational system can be implemented, the profession and patients would be well served by a heightened awareness of the increased number of years required in a constrained work hours environment to achieve proficiency in the independent practice of medicine, especially when procedural competence is required. Such a realization will inevitably result in voluntary lengthening of some residency training programs, particularly in surgical disciplines and those medical specialties with a prominent procedural component.