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ACGME seeks to return trainees’ maximum shifts to 24 hours


 

First-year residents may be permitted to work up to 24 consecutive hours – 8 hours longer than they can now – under a proposal from a task force of the Accreditation Council for Graduate Medical Education (ACGME).

The ACGME Duty Hour Task Force proposes to raise first-year trainees’ work hour limit from 16 hours, reverting to the 24-hour maximum that remained in effect until 2011 – and the existing limit in place for all other residents.

“There is better team continuity of care provided with less micromanagement of resident duty hours,” said Thomas J. Nasca, MD, ACGME chief executive and vice chairman of the task force.

The ACGME instituted the 16-hour cap for first-year residents in the wake of a December 2008 report released by the Institute of Medicine (IOM), “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety.” The ACGME also prohibited 30-hour shifts, which some trainees had been clocking.

“Every 5 years, the ACGME reviews its program requirements,” Dr. Nasca said. “That’s a promise we made to the community and to the public” in July 2003. The most recent changes occurred in July 2011.

Since then, some faculty have contended that shorter work hour limits for the first-year residents are accelerating the frequency of patient transitions and disrupting continuity of care. Many educators also noted that residents would gain more knowledge by monitoring a hospitalized patient during the initial 24 hours.

The proposed changes are “encouraging and courageous,” according to R. James Valentine, MD, FACS, president of the Western Surgical Association.

“This is a real world scenario,” said Dr. Valentine, professor of vascular surgery at Vanderbilt University, Nashville, Tenn. “Medicine is such a complex system. It is not easily constrained by time limitations.”

Requiring a physician to transition a patient’s care at a specific time may help promote the trainee’s well-being; however, it also “robs the resident of the opportunity to see the disease progress and to see the response to the treatment that is being offered. The new rules help strike a balance between bedside education and rest,” he added.

The proposed revisions to training requirements also include phasing out the term “duty” hours in favor of “clinical experience and education,” highlighting that residents’ responsibility to patients takes precedence over any adherence to a schedule or clock. Working a certain number of hospital hours is only one aspect of delivering safe and quality care, the ACGME Duty Hour Task Force noted in its proposal.

The proposal does not change the following, which all are averaged over a period of 4 weeks: a maximum of 80 hours per week, 1 day free from clinical experience or education in 7, and in-house call no more often than every third night.

“It is important to note that the absence of a common 16-hour limit does not imply that programs may no longer configure their clinical schedules in 16-hour increments if that is the preferred option for a given setting or clinical context,” Dr. Nasca wrote in a Nov. 4 letter to the graduate medical education community.

In its December 2008 report, the IOM noted that revamping residents’ work hours alone offered no guarantee of patient safety. It called for increased supervision by seasoned physicians, restrictions on patient caseloads based on residents’ levels of experience and specialty, overlap in schedules around shift changes to decrease the possibility of error in transitioning patients from one provider to another, and broad-based research to examine the outcomes from these changes.

“Surgical residents, when they’re operating, come under very direct supervision by attending physicians,” said Jay Bhattacharya, MD, professor of medicine at Stanford (Calif.) University, who served on the 2008 IOM committee. “That supervision is generally pretty good. Even for a tired resident, the supervision makes it so that the fatigue the trainee faces doesn’t endanger the patient.”

Acknowledging the emerging evidence that physicians are at heightened risk for burnout and perhaps depression, the proposal underscores the need for residency programs and institutions to prioritize the well-being of residents as well as nurses and other hospital personnel.

“Burnout and depression impair a physician’s ability to provide excellent care. Self-care is an important aspect of professionalism, and a skill that must be learned and nurtured under the guidance and role modeling of faculty members,” Dr. Nasca wrote in his Nov. 4 letter.

If the proposal is approved by the ACGME board of directors in February, the changes will be rolled out in July.

The proposal is open to public comment through Dec. 19; comments will be reviewed and considered before a final set of proposed requirements are sent to the ACGME board for approval.

“We’re here to serve the public, and so the focus is on the comments that reflect the most recent and comprehensive evidence and educational outcomes rather than the individual opinions we receive,” Dr. Nasca said.

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