The “New Normal”

To the Editor We commend Desai et al¹ for their thoughtful comparison of the impact of the 2011 regulations with the initial 2003 Accreditation Council for Graduate Medical Education–implemented duty hour restrictions.² The authors have demonstrated that, despite overall increase in trainee sleep duration, the educational aspect of training, such as attendance at daytime conferences, is suffering along with the quality of care provided secondary to discontinuity. They conclude with the recommendation of exploration of new models of training, specifically the structural aspect of how the training is designed. In designing systems to comply with duty hours, we should no longer attempt to shoe-horn old educational models into hour-limited training systems and instead explore the reclamation of educational time within training, embrace alternative educational models, and support programs to ease to the transition from undergraduate to graduate medical education. Prior work has demonstrated that, despite duty hour limitations, the workload that trainees face has not decreased³ and up to one-third of residency activity is of limited educational value.⁴ Mobile technology can also be used to enhance resident efficiency.⁵ Given the inherent need for off-hour shifts in many new systems, educational models need to evolve to adapt to not only varying levels of the learner, but also the availability of the learner. Online learning platforms have been used with great success in education, and their inclusion in residency training will require the understanding that education can indeed take place independently, not in real-time in a conference room, and still be of value. Finally, one must consider that it is not only the number but the quality of handoffs. More importantly, not all handoffs are created equal. Systems can be designed to maximize continuity despite handoffs through the use of intrateam handoffs by having team members work serially so that someone from the team is always present and has both knowledge of and professional responsibility to the patient. This is in contrast to interteam handoffs, when all members on a team work in tandem; when they leave and handoff, no one who has primary knowledge of the patient is left. Together, we must accept that the “new normal” will require novel ideas and approaches as opposed to tweaking the old system.