More Than a Matter of Time

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The safety of these recommendations has never been established. There have been⬎50 cases of death or permanent neurologic injury in children over the past decade from hospital-acquired hyponatremia resulting from the administration of hypotonic flu-id.2–5In a recent contribution toPediatrics, we intro-duced the concept of administering isotonic saline (0.9% sodium chloride) in maintenance fluids to pre-vent hospital-acquired hyponatremia.6In an accom-panying editorial, Holliday et al7 argued that the administration of isotonic saline is unsafe and that hyponatremia results from egregious fluid manage-ment.

In this issue ofPediatrics, a study by Hoorn et al8 supports our hypothesis that the routine administra-tion of hypotonic fluids is dangerous and can result in unnecessary deaths. In this article, Hoorn et al assess the relationship of intravenous fluid adminis-tration and the development of hospital-acquired hy-ponatremia. They found that 10% of children with normal serum sodium at presentation to the emer-gency department go on to develop hyponatremia. Of the 40 patients with hospital-acquired hyponatre-mia, 2 had neurologic sequelae and 1 child died from cerebral edema due to an acute fall in serum sodium from 142 to 128 mmol/L. The main contributing factor for developing hospital-acquired hyponatre-mia was the administration of hypotonic fluids. Since their article was submitted for publication, there have been additional reports of death and hy-ponatremic encephalopathy resulting from hypo-tonic fluid administration.9–11

The data in this article, in conjunction with numer-ous previnumer-ous reports of hospital-acquired hyponatre-mic encephalopathy in children, indicate that the current practice of administering hypotonic mainte-nance intravenous fluids in children is unsafe and should be abandoned. We disagree with the authors’ recommendations that hypotonic fluids should be avoided only in postoperative patients and those with low normal serum sodiums (PNa⬍ 138 mmol/ L). Their data do not support these recommenda-tions, because the majority of patients who devel-oped hyponatremia in their study had a serum sodium⬎137 mmol/L, and the 1 death occurred in a patient with a serum sodium of 142 mmol/L. The administration of intravenous fluids should be con-sidered an invasive procedure, and all hospitalized patients should be considered at risk for developing hyponatremia. The current practice of routinely ad-ministering hypotonic fluids is unphysiologic, given the numerous stimuli for antidiuretic hormone pro-duction in hospitalized children. How many more children will die unnecessarily? One is too many. Many tragic deaths could be avoided by the admin-istration of isotonic saline. Although no one paren-teral fluid can be administered safely to all children, isotonic saline would seem to be the safest fluid for most children. The administration of hypotonic fluid is unnecessary unless there is a free-water deficit or ongoing free-water losses.12 Until proof exists that the administration of isotonic saline could be

harm-ful, the routine practice of administering hypotonic fluids should be abandoned.

Michael L. Moritz, MD

Division of Nephrology Department of Pediatrics Children’s Hospital of Pittsburgh University of Pittsburgh School Medicine Pittsburgh, PA 15213-2538

Juan Carlos Ayus, MD

Department of Medicine

University of Texas Health Science Center San Antonio, TX 78229-3900


1. Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy.Pediatrics.1957;19:823– 832

2. Arieff AI, Ayus JC, Fraser CL. Hyponatraemia and death or permanent brain damage in healthy children.BMJ.1992;304:1218 –1222

3. Halberthal M, Halperin ML, Bohn D. Lesson of the week: Acute hy-ponatraemia in children admitted to hospital: retrospective analysis of factors contributing to its development and resolution.BMJ.2001;322: 780 –782

4. Moritz ML, Ayus JC. La Crosse encephalitis in children.N Engl J Med.

2001;345:148 –149

5. McJunkin JE, de los Reyes EC, Irazuzta JE, et al. La Crosse encephalitis in children.N Engl J Med.2001;344:801– 807

6. Moritz ML, Ayus JC. Prevention of hospital-acquired hyponatremia: a case for using isotonic saline.Pediatrics.2003;111:227–230

7. Holliday MA, Segar WE, Friedman A. Reducing errors in fluid therapy.

Pediatrics.2003;111:424 – 425

8. Hoorn EJ, Geary D, Robb M, Halperin ML, Bohn D. Acute hyponatre-mia related to intravenous fluid administration in hospitalized children: an observational study.Pediatrics.2004;113:1279 –1284

9. Hanna S, Tibby SM, Durward A, Murdoch IA. Incidence of hyponatrae-mia and hyponatraemic seizures in severe respiratory syncytial virus bronchiolitis.Acta Paediatr.2003;92:430 – 434

10. Playfor S. Fatal iatrogenic hyponatraemia.Arch Dis Child. 2003;88: 646 – 647

11. Jenkins J, Taylor B. Prevention of hyponatremia.Arch Dis Child.2004; 89:93

12. Moritz ML, Ayus JC. The pathophysiology and treatment of hy-ponatraemic encephalopathy: an update.Nephrol Dial Transplant.2003; 18:2486 –2491

More Than a Matter of Time


ew topics in graduate medical education have provoked as much comment and controversy as the recent decision of the Accreditation Council for Graduate Medical Education to limit res-ident “duty hours,” defined as all clinical and aca-demic activities related to the residency program. Regulations that went into effect July 1, 2003, limit duty hours to 80 hours per week, averaged over a 4-week period. In addition, residents may spend no more than 24 consecutive hours on duty, although they may remain on duty for up to 6 additional hours, for a total of 30 hours, to participate in didac-tic activities, transfer care of patients, conduct

conti-Received for publication Dec 30, 2003; accepted Dec 30, 2003.

Reprint requests to (M.D.J.) Children’s Hospital, B065, 1056 E 19th Ave, Denver, CO 80218. E-mail:

PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad-emy of Pediatrics.


nuity clinics, and maintain continuity of inpatient medical care. No new patients, defined as any pa-tient for whom the resident has not provided care during the previous 24-hour period (except for pa-tients who are part of the resident’s continuity panel or the panel of the resident’s continuity team), may be accepted after 24 hours of continuous duty.1

One might ask: “Why the fuss in pediatrics?” Many pediatric training programs have been close to 80 hours per week for some time. The requirement that housestaff take on new patients for no more than 24 hours and be on duty for no more than 30 hours is more of a challenge, especially for intensive care and the busiest inpatient rotations, but this repre-sents only a minority of trainees at any one time. Nevertheless, debates about the advisability of lim-iting work hours continue.

The case for limiting work hours is compelling. Scientific data and common sense support the im-portance of state of alertness for doing the best job. At some point, fatigue impairs cognitive abilities and judgment.2–4The precedents of professions such as airline pilot or long-distance truck driving are cited. Safety concerns have limited hours in those profes-sions and others, the argument goes; why not with medical residents? Yet the proposition that cognitive abilities and patient safety are compromised by res-ident fatigue has been difficult to prove.2–7 Studies have not been of the best design or of sufficient statistical power to demonstrate differences in rare adverse events.

One author reasoned that, in any case, adverse events are not the appropriate end point.7 He ob-served that, although fatigue may or may not endan-ger patients, there is little doubt that it leads to impatience and irritability. A tired, irritable resident is not the best person to manage or learn from the complicated physician-patient interactions that arise in contemporary clinical care. Patience and capacity for empathy are likely to be in short supply.

Objections to limiting work hours have centered on concerns that continuity of care will suffer and that a professional sense of ongoing responsibility to patients will be replaced gradually by a fragmented, shift-work approach.8Neither these possibilities nor ways to mitigate them have been studied systemati-cally.

The greater problem with limiting resident work hours is that limitation of work hours represents an oversimplified approach to a complex problem.9 With regard to patient safety, proper supervision is at least as important as alertness. However, the real challenge (“the monster under the bed”) is that grad-uate medical education needs to be rethought from top to bottom.

The goal of graduate medical education is to pro-duce competent, appropriately self-confident physi-cians. Education needs to occur in an environment that enhances rather than compromises patient safety. The task is daunting. The volume of informa-tion a resident must master is increasing exponen-tially, yet the duration of training in pediatrics re-mains constant at 33 months. That is not to say that a simple increase in the duration of training is likely

to guarantee a broadly competent pediatrician any more than a simple decrease in work hours is to guarantee patient safety.

The monster under the bed is the intimidating need for a comprehensive rethinking of how gradu-ate medical education should be done. Our quasi-apprentice approach no longer suffices. Even a work week far longer than 80 hours would be insufficient to “learn by doing.” There is too much to learn and do. The situation is exacerbated by the considerable inefficiency of a resident’s workday (and night).10 Fortunately, technology soon may reduce the time spent tracking down (or, worse, working around a lack of) patient information.11

The challenge for us in pediatrics is not different than that for all graduate, and for that matter under-graduate, medical education. The old model of “see one, do one, teach one” is unacceptable and ineffec-tive. The polar alternative of a supervisor monitoring every move and interaction is equally unsatisfactory. We know that retention from didactic lectures is poor. Yet most of us continue to lecture residents; residents, perhaps out of habit or for lack of alterna-tives, continue to request lectures. The situation is analogous to the anecdote of the man who drops his key in the dark yet continues to look under the street lamp because that is the only place he can see.

Opportunities for research are enormous. Do we introduce minicourses on a variety of basic topics (eg, fluids and electrolytes) into residency programs? Should we include an assessment of competence? If so, how should that be done? How do we teach housestaff to deal with chronic illnesses and behav-ioral problems in an environment in which longitu-dinal knowledge of family dynamics is nearly impos-sible? Should we use simulated patients? The honest answer to these questions and a long list of others is that we don’t know. We need to find out.

First, we need more pediatricians and other med-ical educators trained to ask and answer such ques-tions. Second, we need a source of funds to support their studies. Marginally fewer hours with which to work is only a small aspect of a large challenge.

M. Douglas Jones, Jr., MD

Department of Pediatrics Children’s Hospital

University of Colorado Health Sciences Center Denver, CO 80218


1. Accreditation Council for Graduate Medical Education. Duty hours requirements for programs in pediatrics and the pediatric subspecial-ties. Available at:㛭PedDocs/Ped㛭dutyHours.pdf. Accessed December 10, 2003

2. Veasey S, Rosen R, Barzansky B, Rosen I, Owens J. Sleep loss and fatigue in residency training: a reappraisal.JAMA.2002;288:1116 –1124 3. Gaba DM, Howard SK. Fatigue among clinicians and the safety of

patients.N Engl J Med.2002;347:1249 –1255

4. Accreditation Council for Graduate Medical Education. The ACGME’s role in protecting education, patient safety and resident safety. Avail-able at: Accessed December 10, 2003

5. Storer JS, Floyd HH, Gill WL, Giusti CW, Ginsberg H. Effects of sleep deprivation on cognitive ability and skills of pediatrics residents.Acad Med.1989;64:29 –32


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6. Whetsell JF. Changing the law, changing the culture: rethinking the “sleepy resident” problem.Ann Health Law.2003;12:23–73

7. Green MJ. What (if anything) is wrong with residency overwork?Ann Intern Med.1995;123:512–517

8. Holzman IR, Barnett SH. The Bell commission: ethical implications for the training of physicians.Mt Sinai J Med.2000;67:136 –139

9. Drazen JM, Epstein AM. Rethinking medical training–the critical work ahead.N Engl J Med.2002;347:1271–1272

10. Moreno MA. Resident stress revisited: a senior pediatric resident’s point of view.Pediatrics.2003;112:411– 413

11. Bates DW, Gawande AA. Improving safety with information technol-ogy.N Engl J Med.2003;348:2526 –2534

Addressing the Accreditation

Council for Graduate Medical

Education Competencies: An

Opportunity to Impact Medical

Education and Patient Care

ABBREVIATION. ACGME, Accreditation Council for Graduate Medical Education.


he Accreditation Council for Graduate Medical Education (ACGME) rolled out a document1in 1999 that perhaps could have the greatest im-pact on medical education as a continuum since the Flexner report and ultimately could influence the quality of healthcare of our nation (that is, if those of us responsible for medical education at all levels see this as an opportunity and not as a way to simply satisfy an external accrediting body). This document was originally designed for resident education, but the competency-based concepts have already perme-ated the thinking in and stimulperme-ated the responsible parties for undergraduate education. Those respon-sible for continuing medical education have previ-ously questioned the efficacy of traditional continu-ing education and want to see knowledge and performance linked.

Current word of mouth has it that residency pro-grams are being cited by residency review commit-tees for not demonstrating an effort to address and implement the competencies. Why is this? On the surface, it seems that physicians responsible for res-idency training are deciphering the competencies as best they can, working within their own programs to create a competency-based curriculum. This is an overwhelming and daunting challenge for many rea-sons, not the least of which are a lack of national guidelines, limited resources, limited time, not un-derstanding definitions of the competencies, not knowing how to evaluate specific areas, non– evi-dence-based evaluation techniques in the ACGME

tool box, and perhaps, most importantly, not having any formal background in the process of medical education.

So, how do we approach this challenge so that we can assure that our trainees will be the most compe-tent, caring, humanistic, and bright physicians? I have reflected on this enormous task based on my long-time interest and training in medical education and my travels to many programs throughout the country, listening to the concerns of training-pro-gram and clerkship directors.

I believe I understand the problems and am sug-gesting solutions that I believe will empower and enable us as educators to make this competency-based system work more efficiently and effectively. The solutions can be divided into the following cat-egories: 1) faculty development; 2) collaboration; 3) empowering of residents; 4) promoting scholarship for our junior faculty; 5) developing simulations as a way to observe performance; 6) timing and win-win strategies; and 7) involving our “silent” stakeholders: parents and patients.


There has never been a more pressing reason to train faculty leaders responsible for education on educational theory and applicability. This training, which can consist of brief interactions (1–2 hours) as part of an approach to defining and implementing the competencies, will enable these faculty members to lead others in high-stakes areas of concern (e.g., evaluating resident performance). These sessions should be fun, applicable to real-life situations, and focused on adult learning principles.2 They should be accompanied by brief readings on key topics such as professionalism. Some of the questions interested faculty sitting at the table can address are: How do we define it? How do we teach it? Where do we teach it? What do we teach? How do we measure perfor-mance? The way this will happen is if chairs of departments see faculty development as a priority, i.e., budget for it and delegate the responsibility to training-program and clerkship directors. The payoff should be more innovative programs that set the bar for resident performance and certify that residents are reaching that bar and beyond. That is how we can assure the public that we are producing the best and most caring doctors.


In medicine, it is generally not our nature to col-laborate. We are forever competing against one an-other as individuals, departments, and schools. Be-cause there are no national guidelines on how to define, teach, and assess the competencies, we should be looking to each other on how our efforts are working or not working.3 This collaboration should occur within departments, within schools, specifically across departments, and across schools and departments. General pediatric departments and all the subspecialties within them must develop ap-proaches for assuring that residents achieve the com-petencies. For example, if each group were looking

Received for publication Jan 26, 2004; accepted Feb 2, 2004.

Address correspondence to Larrie Greenberg, MD, Department of Pediat-rics, Children’s National Medical Center, Office of Faculty Affairs, 2300 Eye St, NW, George Washington University School of Medicine and Health Sciences, Washington, DC 20037. E-mail: larrie㛭 PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad-emy of Pediatrics.


DOI: 10.1542/peds.113.5.1396



M. Douglas Jones Jr.

More Than a Matter of Time


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More Than a Matter of Time

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