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Hospitalists Can Help Solve Residency Duty-Hour Issues

From: The Hospitalist, July 2012

HM appears well-positioned to benefit from changes brought about under the Accreditation Council for Graduate Medical Education’s residency program regulations.

by Christopher Guadagnino, PhD

It’s been one year since the Accreditation Council for Graduate Medical Education’s (ACGME) most recent residency program regulations took effect, updating standards put into place in 2003. The regulations are the latest manifestation of an ongoing challenge in medical training: how to strike the right balance of optimal clinical training with patient safety, resident well-being, and other concerns.

Clearly the most controversial change in the latest regulations is the restriction of first-year residents to a work shift of no more than 16 hours and older residents to 24 hours, with an additional four hours to manage transitions in care (previously, 30-hour shifts were permitted for all residents). ACGME applied the 16-hour restriction after extensive discussions with members of an Institute of Medicine committee that drafted a report at the request of Congress that explored the dangers to patient care of sleep-deprived caregivers. The IOM report argued that revisions to medical residents’ workloads and duty-hours were necessary to better protect patients against fatigue-related errors and to ensure that residents get the best educational experience.1

This month, the ACGME begins its annual reviews of institutions to gauge the impact of the new regulations. While few expect the ACGME to find decisive answers regarding optimal work-hour regulations for residents, the 16-hour rule has both its opponents and supporters. On balance, HM appears to be well-positioned to benefit from the changes, having been given yet another opportunity to demonstrate value by helping their institutions weather the changes, enhance the residency training experience, and support the patient safety imperative.

Is 16 the Magic Number?

In defending the new rules last year, ACGME CEO Thomas J. Nasca, MD, acknowledged that the evidence linking long duty-hours and patient safety is mixed, while also explaining that another part of the rationale for limiting shifts for the youngest residents was to ease them into the profession. Older residents, he said, must be taught to recognize and manage the fatigue they will encounter regularly in their actual clinical practice, where hours are not regulated.

“It makes sense how ACGME has structured this—giving trainees the chance to learn in a more measured way, while recognizing that more experienced residents have more mature judgment,” says Daniel D. Dressler, MD, MSc, SFHM, FACP, hospital medicine associate division director for education, and associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory University School of Medicine in Atlanta. “I believe it’s an overall positive move, in terms of morale and work/life balance.”

Others disagree. Patient safety expert Lucian Leape, MD, adjunct professor at Harvard School of Public Health, decried that the ACGME rules did not apply to all residents, just those in their first year, and he rejected the assumption that one can learn to tolerate sleep deprivation.2 HM pioneer Bob Wachter, MD, MHM, professor, chief of the division of hospital medicine, and chief of the medical service at University of California San Francisco Medical Center, agrees the work-hour restrictions are here to stay—and are a good thing. At his blog Wachter’s World, he recently posted that research shows “prolonged wakefulness” degrades cognitive skills, and equates to a blood-alcohol level of 0.1, or “legally drunk in every state.”

“Even without strong evidence one way or the other, if it has improved safety, I think 16 hours is probably right for interns, and 24-plus-four hours for second-year residents and above. It’s the ACGME’s best guess, to date, of the right balance,” says Jeffrey G. Wiese, MD, SFHM, FACP, associate dean for graduate medical education, director of the internal medicine program at Tulane University School of Medicine in New Orleans, and former SHM president. “It’s no huge intellectual stretch to say that someone who’s been up for 32 hours is not in the best condition to make optimal patient-care decisions.”

While preserving optimal cognitive abilities is important for all physicians, ACGME’s new work-hour limits matter even more to specialties like surgery, which rely heavily on manual dexterity skills, Dr. Wiese suggests. Ironically, surgical specialty societies have been among the most critical of the new limits.

“My surgical colleagues have been particularly vocal critics of the new work-hour limit,” says Dr. Dressler, noting that Emory’s residency programs are smaller and have greater challenges in adjusting for fewer work hours as they rely more heavily on residents for certain clinical tasks than do other specialties.

Ideally, Dr. Wiese maintains, resident duty-hours should be increased gradually based on progressively demonstrated levels of ability and competence by individual residents, regardless of program year. Such milestone-based accountability is supported by SHM as well as several other medical societies.

Continuity of Care

A downside to the work-hour limit is its potential to disrupt both the continuity of care and the learning process, as fewer patients are likely to be followed by a single resident from admission to resolution of a case. Dr. Wachter, who is chair of the American Board of Internal Medicine (ABIM) and a former SHM president, acknowledges this sacrifice, noting that care teams at his hospital inherit nearly half their patients as handoffs from night admitters, and some never know handed-off patients as well as those they admitted themselves.

“In a system in which half the patients are cared for by two sets of doctors during these crucial stages [early assessment, data gathering, and initial patient response], neither group fully sees this arc play out, and their education suffers,” he wrote on his blog.

New limits means “less flexibility,” says Dr. Dressler, “and it can become a hindrance to completing the work-up of a patient—like not being able to put a central line in at 8:30 p.m. ... Some trainees feel they have less continuity with their patients because of the shorter hours.”

Jeffrey G. Wiese, MD, SFHM, FACP It’s no huge intellectual stretch to say that someone who’s been up for 32 hours is not in the best condition to make optimal patient-care decisions.

—Jeffrey G. Wiese, MD, SFHM, FACP, associate dean, graduate medical education, director, internal medicine program, Tulane University School of Medicine, New Orleans, former SHM president

Thoughtful management is required to minimize schedule disruption and maximize learning opportunities, he adds. “We’ve decided that our interns will have five overnight shifts over 10 days as part of one of their 30-day rotations. It’s important that interns get overnight experience before their second year,” Dr. Dressler says. “We had to incorporate three interns per team instead of two. Any way you slice it, you’re going to need additional manpower from other sources.”

Such workforce issues are hot topics in teaching hospitals across the country, Dr. Wiese says. He also warns that using hospitalists solely as “resident extenders” is not sustainable. “If an academic program is using hospitalists as stopgap labor, they do so at the risk of accelerating burnout,” he says.

Hospitalist Opportunity

Hospitalists can and should, however, take full advantage of a much-needed niche that the new ACGME regulations have called attention to: the need for expertise in minimizing patient-care disruptions resulting from more frequent patient handoffs.

“Hospitalists have an opportunity to get more involved in residency training programs by sharing their knowledge of effective patient handoff protocols,” Dr. Dressler says. “Hospitalists have treaded those waters for over a decade. We’ve learned a lot about structuring handoff information effectively, and we can inform training programs about those issues.”

The increased urgency of effective handoff management might even lead to an increased investment in HM programs, Dr. Dressler believes. “The expectation, of course, is that we are able to demonstrate effective patient handoffs—and show that we’re ‘walking the walk,’ and not just talking about it,” he says.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

What’s in the Rules

The ACGME’s residency training regulations went into effect July 1, 2011. Among the requirements:

  • First-year residents are limited to a shift of no more than 16 hours. Other resident shifts may last up to 24 hours, with an additional four hours to manage transitions in care. (In 2003, all residents were permitted 24-hour shifts with six hours for transition-of-care management.)
  • A physician must be available to provide direct supervision for first-year residents at all times, as needed.
  • Residents and faculty must be trained to recognize sleep deprivation. Fatigue-management programs must be in place (e.g. naps or backup call schedules), and institutions must provide sleep facilities and/or safe transportation options for fatigued residents.
  • Clinical assignments must be designed to minimize transitions in patient care, and residents must be competent in communicating with team members in handoffs. Residents must also participate in interdisciplinary clinical quality-improvement (QI) and patient safety programs.
  • Residents may work up to 80 hours per week, averaged over four weeks (consistent with 2003 regulations). All moonlighting, however, must be included in the work-hour limit, and first-year residents are not permitted to moonlight.

Source: www.acgme.org/acwebsite/dutyhours/dh_index.asp

References

  1. Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. Institute of Medicine website. Available at: http://www.nap.edu/catalog.php?record_id=12508#toc. Accessed May 1, 2012.
  2. Krups C. Residency programs scramble to adopt changes. American Medical News website. Available at: http://www.ama-assn.org/amednews/2011/07/11/prsa0711.htm#s1. Accessed May 1, 2012.

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