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Resident work hours, supervision face new round of restrictions

An ACGME proposal calls for placing new work-hour limits on first-year residents and increasing levels of oversight.

By — Posted July 5, 2010

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In 2003, resident workweeks were limited to 80 hours to improve patient safety and end the 120-hour workweeks common during training.

Seven years later, the Accreditation Council for Graduate Medical Education has proposed more changes that call for increased supervision of physicians-in-training, tighter limits on moonlighting and reduced work hours for first-year residents.

The goal is to reduce medical errors, ensure patient safety and improve quality of care, said Thomas Nasca, MD, ACGME chief executive officer.

"We realize that patient safety is about more than resident duty hours," Dr. Nasca said. "These standards were written specifically to place the patient at the center, not the resident."

If approved, the revisions, published online June 23 in the New England Journal of Medicine, would take effect in July 2011. The workweek maximum would remain at 80 hours.

Many of the changes -- such as new workload limits, greater supervision requirements and on-call duty restrictions -- were influenced by a December 2008 Institute of Medicine report. But other IOM recommendations were not embraced.

For example, the IOM called for reducing the maximum work shift from 24 to 16 hours. But the ACGME is seeking to limit only first-year residents to 16 hours, while maintaining 24-hour maximum shifts for other residents.

Organizations such as the American Medical Association and the Assn. of American Medical Colleges say the proposed revisions include needed updates to help prevent medical errors by fatigued residents. The AMA supports an 80-hour workweek, as well as flexibility for residents in different specialties.

"The American Medical Association commends the [ACGME] for its thoughtful work toward ensuring excellent resident education, improving patient safety and quality, and balancing the many views on resident duty-hour standards," AMA Board of Trustees Chair Ardis Dee Hoven, MD, said in a statement.

But one longtime observer is skeptical.

"The improvements in the new ACGME guidelines are largely swamped by the failure to cover the majority of medical residents with the protection of not having to work more than 16 hours continuously," according to a statement by Sidney Wolfe, MD, director of the Health Research Group at Public Citizen, a consumer advocacy organization.

Limiting resident duties

First-year residents are the focus of several proposed changes. For example, they would be prohibited from moonlighting or being on in-hospital call.

"The data is clear that first-year [residents], who are the least-experienced and have the least practical knowledge, are most likely to make errors," Dr. Nasca said.

Joanne Conroy, MD, AAMC's chief health care officer, said research has not shown a clear link between reduced resident work hours and improved patient safety. But by placing tighter limits on first-year residents, the new standards would help protect the "most vulnerable" residents and their patients.

"There is nothing more tragic for a new physician than to be part of a medical error. It affects them as future physicians," she said.

The associate program director of the general surgical residency program at the University of Nebraska Medical Center, Chandra Are, MD, said some residents complain that they lose valuable training opportunities because of work-hour restrictions. But a high level of training can be attained without compromising patient safety, he said.

"We all should be resident advocates, but at the end of the day, we're patient advocates. We need to find a happy medium between the two," said Dr. Are, who is also an assistant professor of surgical oncology at the university.

Dr. Are said more variation in work-hour restrictions is needed to accommodate different specialties.

"They kept in mind that different levels of training have different levels of responsibilities. I wish they had given the same flexibility for different specialties," he said. "In surgery, it's hard to tell someone at 10 p.m., halfway through the surgery, 'You're done, you have to leave.' "

The 2003 rules required programs to provide "appropriate" faculty supervision of residents. Under the proposed new rules, the ACGME specifies that programs must provide three levels of supervision, including direct and indirect supervision, as well as oversight by a physician who would review patient cases. First-year residents would have direct supervision or someone readily available at the institution at all times.

These revisions won't be a big adjustment for many institutions that already have varying levels of supervision in place, said Julia McMillan, MD, professor of pediatrics and director of the pediatric residency program at Johns Hopkins University School of Medicine in Baltimore. Johns Hopkins already has varying levels of supervision.

Improving handoffs

Dr. Nasca said the ACGME revisions are intended to "minimize handovers in patient care," when communication errors often occur.

A resident's workload would be based on experience, and the complexity and severity of a patient's condition. In rare cases, residents would be allowed to stay beyond their shift to continue care.

But Dr. McMillan said the proposed changes would reduce the amount of time -- from six hours to four -- that residents are allowed to stay beyond their shift to transfer patient care or participate in educational activities. That may require hiring additional staff to handle shift changes.

"It's really amazing how much difference two hours make," said Dr. McMillan, also associate dean for graduate medical education at Johns Hopkins. "This is going to be expensive for hospitals."

The changes would require annual ACGME site visits, costing institutions about $12,000 to $15,000 per year, Dr. Nasca said.

A public comment period on the recommendations runs through Aug. 9. A final decision will be made by the ACGME's board.

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ADDITIONAL INFORMATION

Resident work hours

View in PDF

Click to see data in PDF.

The Accreditation Council for Graduate Medical Education in June released proposed revisions of resident work-hour restrictions. Here is a comparison with the 2003 ACGME standards and 2008 Institute of Medicine recommendations.

Supervision

2003 ACGME requirements: Programs ensure supervision by qualified faculty.
2008 IOM recommendation: Supervision standards are set by a residency review committee; in-house supervision is provided for first-year residents.
2010 ACGME proposal: Residents and attendings inform patients of their roles, while program directors and faculty assign progressive responsibilities. Residents must have three levels of supervision, with a physician available to provide direct supervision for first-year residents.

Workload

2003 ACGME requirements: Assignments recognize that residents and faculty are both responsible for patient safety and welfare.
2008 IOM recommendation: Residents have adequate time for patient care and reflection. Complexity of illness and resident competency is considered in setting appropriate caseloads.
2010 ACGME proposal: Workload is based on patient safety, severity and complexity of patient cases, available support, and resident training and education.

Maximum shift length

2003 ACGME requirements: 30 hours (with 24 hours to admit patients and 6 hours for transition and educational activities).
2008 IOM recommendation: 16 hours; extended duty of 30 hours (with 5 hours sleep after 16 continuous hours) only every third night.
2010 ACGME proposal: 16 hours for first-year residents; 24 hours for other residents with another 4 hours for transition and education. Residents must be informed of alertness strategies, and a nap is strongly suggested after 16 hours of continuous duty.

Minimum time off between scheduled shifts

2003 ACGME requirements: 10 hours.
2008 IOM recommendation: 10 hours after day shift; 12 hours after night shift; 14 hours after extended duty period and no return before 6 a.m. the next day.
2010 ACGME proposal: 10 hours (with minimum of 8 hours duty-free between shifts, or 14 hours duty-free after 24 hours of in-hospital duty).

Mandatory off-duty time

2003 ACGME requirements: 24 hours off per week averaged over 4 weeks.
2008 IOM recommendation: 24 hours off per week, no averaging; one work-free weekend per month.
2010 ACGME proposal: 24 hours per week averaged over 4 weeks; no home call on free days.

Moonlighting

2003 ACGME requirements: Internal moonlighting is considered part of the 80-hour weekly limit.
2008 IOM recommendation: Internal and external moonlighting are included in the 80-hour weekly limit; approval is required by program director.
2010 ACGME proposal: Internal and external moonlighting are included in the 80-hour weekly limit; no moonlighting allowed for first-year residents.

Source: "The New Recommendations on Duty Hours from the ACGME Task Force," New England Journal of Medicine, published online June 23 (link)

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Work-hour limits seen as boosting resident satisfaction

Residents expressed greater satisfaction in the clinical and educational environment after work-hour restrictions took effect in 2003, according to a study in the July Academic Medicine.

Researchers analyzed surveys of 19,605 residents at Dept. of Veterans Affairs medical centers between 2001 and 2007. They compared responses before and after the Accreditation Council for Graduate Medical Education implemented work-hour restrictions in 2003.

The survey classified the medical specialty category as including internal medicine, neurology, and physical and rehabilitation medicine. The surgery category included surgery and anesthesiology.

Residents surveyed after the restrictions were in place expressed greater satisfaction with their educational, clinical, physical and working environments, as well as with their supervisors.

Of those surveyed after the rules took effect, 95.8% of medical specialty residents reported overall satisfaction, a 7.4 percentage point increase from 2003. Among surgery residents, 91.8% surveyed after 2003 expressed overall satisfaction, compared with 89.9% before the changes.

The greatest increase in satisfaction occurred in attitudes toward clinical environment.

About eight in 10 medical specialty residents said they were satisfied with their clinical environment. About six in 10 expressed satisfaction prior to the ACGME rules.

Among surgical residents, 93.1% expressed satisfaction with their clinical environment under the new rules, up 33.2 percentage points from 2003.

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External links

"The New Recommendations on Duty Hours from the ACGME Task Force," New England Journal of Medicine, published online June 23 (link)

"Studying the Effects of ACGME Duty Hours Limits on Resident Satisfaction: Results From VA Learners' Perceptions Survey," abstract, Academic Medicine, July (link)

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