Toward “The Genius of the AND”: Balancing Professionalism and Duty Hour Requirements in Graduate Medical Education

In this perspective, we propose a bridging approach and some measures that endorse both professionalism and duty hour compliance. Specifically, both goals can be bridged by creating a culture in which professionalism is celebrated, for example, by publicly telling stories about exemplary professionalism by trainees and by consistently affirming the humanism in medicine. Another bridging opportunity is to optimize continuity of care and communication during handoffs. Measures, such as using a sign-out tool and structuring the sign-out conversation to assure completeness and efficiency, value professionalism and duty hour rules.

Overall, we applaud and encourage the pursuit of creative efforts toward “the genius of the AND” in bridging duty hour compliance and professionalism.

In their book Built to Last: Successful Habits of Visionary Companies, Collins and Porras1 discuss “the genius of the AND” as a way to celebrate the value of bridging seemingly opposite goals. They also caution against assuming that we must choose between what appear to be competing goals rather than seeking opportunities to satisfy both. They call this assumption of dichotomous thinking “the tyranny of the OR.” There is powerful creative value in moving from a dichotomous mindset, in which goals seem mutually exclusive, to a bridging or mitigating mindset, in which goals are perceived to be at least compatible or, even better, mutually reinforcing.

In this context, we believe that the goals of enhancing professionalism among physicians-in-training and of assuring compliance with duty hour regulations offer an opportunity to bridge potentially competing goals. Consider the following everyday clinical scenario: A resident is within a half hour of the limit on continuous duty hours. The condition of one of her patients deteriorates acutely and needs immediate attention. For the resident, this scenario juxtaposes the requirement to be free from patient responsibilities within the next 30 minutes and her professional, medical obligation to her patient's immediate welfare. The frequency and pressure of this clinical scenario is recognized by a specific provision in the new Accreditation Council for Graduate Medical Education (ACGME) duty hour requirements.

This provision acknowledges the occasional need to extend beyond the consecutive duty hour limit when caring for a single patient whose clinical condition requires immediate and continuous attention by the trainee. Specifically, “in unusual circumstances, residents, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family.”2 In our view, this relaxation of prior regulations is a laudable recognition by the ACGME that trainees must be empowered both to occasionally extend their time in caring for patients and to make this judgment on their own. This affirms professionalism because the determination of how one allocates one's time and attention is an essential dimension of what professionals do.

In trying to reconcile duty hour rules and professionalism, many observers rightly point out concerns about the “tyranny of the OR.” They note that duty hour regulations, however justified to avoid exhaustion and preserve human safety, necessarily threaten professionalism. Rybock3 stated that “although we have added ‘professionalism’ as a training goal, we began giving our trainees the choice between abandoning a patient and lying….” (ie, that they complied with duty hour rules when, in fact, they may have exceeded duty hour limits to satisfy their own sense of professionalism). Similarly, in a survey of 111 key clinical faculty members from 39 training programs, Reed et al4 reported that 51% of respondents felt that residents' professionalism had worsened and 73% felt that residents' accountability to patients had declined as a result of the duty hour limit. Some experts have observed an adverse, unintended consequence of duty hour rules, in which trainees perceive themselves as being “on the clock” with a hard stop to their commitment, when their “time is up.”

In the face of a prevailing “either-or” mindset, it is especially important to develop new training paradigms that reinforce trainee compliance with duty hours while asserting the primacy of professionalism. We advise that programs mitigate the “either-or” mindset by championing and supporting the vital need, albeit rare, to extend commitment beyond one's usual duty hour limit.

Additional ways of bridging these potentially competing demands are required, such as creating a culture in which professionalism is celebrated. The new Carnegie Foundation review of medical education, Educating Physicians,5 provides an important example. Cooke et al5 recount the poignant story of a Mayo Clinic resident who, in caring for a frightened, terminally ill patient from Europe, scoured local stores for the patient's favorite beer and smuggled the beer to the inpatient ward, thereby most likely violating hospital policy but satisfying a deep, empathic human need. In another powerful call for empathy and professionalism, Berwick6, as the proud father of a graduating physician, reminded the 2010 graduating class of Yale Medical School of “a secret—a mystery”:

Resounding through both of these examples is a profound commitment of professionalism. The first anecdote describes the act of meeting the patient's needs at the expense of personal time and possible censure and the second invites young graduates to step outside the power of the doctor's role, to meet the human needs of those we serve.

Program directors wanting to celebrate professionalism in a duty hour–constrained world should tell these stories and celebrate their trainees' acts of professionalism. They should explicitly seek stories of professionalism, private and in public, and congratulate trainees who have distinguished themselves through these acts. Thus, training program and graduate medical directors will demonstrate the critical leadership behaviors of “modeling the way” and “encouraging the heart.”7 Most important, faculty must role model this blended professionalism in which the “best” care for the patient is delivered with acute sensitivity to one's performance limits. In this way, a culture of professionalism is affirmed and duty hours are viewed not as a limitation of trainees' commitment but as an affirmation that trainees must bring their best performance in service of their patients' well-being.

Another opportunity to find “the genius of the AND” for professionalism and duty hour compliance is to optimize continuity of care and communication during handoffs of care. Because duty hour requirements have increased the frequency of such handoffs, which pose risk for clinical errors8 and for patient dissatisfaction,9 the mandate for patient welfare10 requires careful and seamless transitions of care between providers. The mandate of professionalism should encourage trainees and program directors alike to optimize systems that facilitate communication for handoffs as well as to develop curricula that teach best practices. Programs like the “Hand-off Clinic” within the University of Chicago's Roadmap,10 which explicitly seek to develop professionalism by framing patients as “humans needing continuity of care” rather than as “someone else's job,” are laudable efforts. In another initiative to optimize handoffs, the Cleveland Clinic helped develop a “sign-out report” within the electronic medical record that standardizes and enhances the information that is conveyed during trainees' handoffs. This tool allows residents and fellows to use a specific electronic medical record template report custom-designed to communicate key clinical details to colleagues assuming the patient's care. The sign-out tool is sufficiently flexible to be used by the team for prerounding and team rounding activities.11 As another benefit, medical students gain exposure to the tool, which provides an opportunity to teach the importance of reducing errors during transitions of care.

Finally, lessons from transition-of-care models, developed as part of the “Patient-Centered Medical Home” (PCMH), may provide fresh ideas for teaching and advocating professionalism and care transitions. The principles of the PCMH include whole-person orientation and coordination of care for patients across all elements of the complex health care system.12 Acknowledging that the PCMH has implications for training, the American College of Physicians recommends fundamental changes in workforce and training policies.13 

These 3 steps—implementing an “exception clause” to allow the occasional violation of an absolute duty hour limit in service of patient welfare, routinely celebrating acts of professionalism by trainees to reinforce a culture of professionalism, and developing systems and curricula to optimize continuity and transitions of care—represent first steps. Further research will be needed to affirm professionalism in the face of forces, like duty hour limits, that can be seen as threats to professionalism. We believe that the pursuit of these bridging solutions is especially needed in the current climate. We encourage others to exercise the “genius of the AND” in service of new, creative solutions to preserve and enhance professionalism among trainees.