January 1, 2011 | Health System Risk Management


Approximately 1,000 hospitals in the United States participated in graduate medical school education programs in 2007, serving as teaching sites for physicians in 1 or more of 130 specialties and subspecialties (AAMC; American Board of Medical Specialties). The American Medical Association (AMA) and the Association of American Medical Colleges (AAMC) estimate that during the academic year 2009-2010, 109,840 physicians were in training in 8,875 programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) in the United States (Brotherton and Etzel).

Physicians in training are typically referred to as “residents” or “fellows” and provide direct patient care in teaching hospitals and at other participating sites that have an affiliation agreement or a letter of agreement with a sponsoring organization that allows residents to obtain educational experiences in a healthcare facility’s various clinical departments. Typically, the sponsoring institution assumes ultimate responsibility for the postgraduate educational program, including assignments at participating sites. Participating sites may be teaching hospitals, organized healthcare delivery systems, community hospitals, private medical practices, nursing homes, and federally qualified health centers, among other healthcare provider venues. (ACGME)

Fundamental to postgraduate medical education is in-depth, hands-on experience caring for patients. A physician in training typically works under the supervision of attending physicians and more senior residents and fellows. Trainees may work many hours at a stretch with only limited time to sleep or rest. Notably, ACGME standards implemented in 2003 permitted as many as 30 consecutive hours of wakeful duty, as well as an 80-hour work week averaged over four weeks. Long continuous shifts and heavy case loads are conditions of training that commonly exist during a trainee’s first year of postgraduate training but may persist during specialty training programs that extend over a period of three to seven years. (IOM)

Adding to the burden of work hours for some trainees is financial indebtedness as a result of student loans accumulated over undergraduate and graduate years. Thus, trainees may actively seek “moonlighting” opportunities within or outside of the sponsoring organization or participating sites, even after completing a long shift. (Collier...

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