Residents, Training Directors Get New Duty-Hour Rules

The Accreditation Council for Graduate Medical Education (ACGME) has approved a set of requirements for resident work hours and trainee supervision that retains the current duty-hour limit of 80 hours a week, averaged over four weeks, but specifies more detailed directives for levels of supervision necessary for PGY-1 trainees.

The new standards, which will go into effect in July 2011, reduce duty periods of first-year residents to no more than 16 hours a day. Moonlighting is prohibited for first-year trainees, and they must have 10 hours free of duty between scheduled duty periods.

The standards were developed after a 16-month review of the scientific literature on sleep issues, patient safety, and resident training by a 16-member task force of the ACGME. They were first posted for 45 days for public comment in late June, and when the comment period closed, the task force reviewed and considered comments submitted by interested parties before presenting them to the board for final approval.

“These new standards are a cohesive whole,” said Thomas Nasca, M.D., M.A.C.P., chief execut ive officer of ACGME and vice chair of the task force, in a statement. “Implementing them will require small changes in some programs and large changes in others, all with the goals of ensuring patient safety, that the next generations of physicians are well trained to serve the public, and that residents receive their training in a humanistic learning environment.”

For residents beyond the PGY-1 year, the ACGME requirements include the following:

The new rules are slightly less stringent in several areas than those proposed in the Institute of Medicine's (IOM) 2008 report, “Enhancing Sleep, Supervision, and Safety.” For instance, regarding maximum shift length, the IOM said that residents could work up to 30 hours, including up to 16 hours admitting patients, but with a five-hour protected sleep period between 10 p.m. and 8 a.m., and with the remaining hours reserved for transition and educational activities. The IOM also said no resident should work more than 16 hours without a protected sleep period.

Regarding minimum time off, the ACGME rules state that “intermediate level residents [as defined by the Review Committee for each specialty]. . . must have eight hours between scheduled duty periods, and at least 14 hours free of duty after 24 hours of in-house duty.” But the IOM called for 10 hours off after a day shift, 12 hours off after a night shift, and 14 hours off after any extended duty period of 30 hours for all residents.

The ACGME rules add that “residents in the final years of education [as defined by the Review Committee for the specialty] must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or extended periods.”

The consumer advocacy group Public Citizen, along with the Committee on Residents and Interns and the American Medical Student Association—which together are petitioning the government to oversee resident duty hours (see APA Urges Govt. to Reject Proposal for Monitoring Resident Hours)—said in their petition that the new rules “fall far short of the improvements recommended by the IOM and those necessary to protect patients and resident physicians from harm.”

In remarks to Psychiatric News, Sheldon Benjamin, M.D., president of the American Association of Directors of Psychiatric Residency Training, underscored the difficult balance that training programs must maintain among ensuring patient and physician safety, providing quality training to residents, and maintaining adequate staff to cover clinical demand.

“Duty-hour compliance has not been nearly as problematic for psychiatry as it has for other specialties,” Benjamin said. “But the new ACGME duty-hour regulations present a number of issues that both psychiatry training directors and psychiatry as a field will have to confront.”

He noted especially that foreshortened resident work hours have the effect of creating more frequent patient care “handoffs.”

“More frequent care transitions increase the chances of errors,” he said. “Therefore, the ACGME did not propose as drastic of restrictions for senior residents. In fact, ACGME has allowed for exceptions to be made that would allow a senior resident to remain on duty . . . when a senior resident is caring for a particularly ill patient and a handoff of patient responsibility would increase risk.

“The new 16-hour duty restriction for interns and the need for in-house supervision will be more burdensome for small training programs and departments, which are more likely to rely on interns for nighttime coverage and less likely to have large faculties or financial resources to provide the direct supervision of interns needed when they are on duty,” Benjamin said. “This will, ironically, result in increased work burden for more senior trainees, possibly more handoffs of care, and possibly decreased numbers of residents present during daytime hours for educational conferences and training activities.”

He added that the new regulations will require training programs to think carefully about the competencies residents must demonstrate as they move toward independent practice.

“In some ways this is a natural progression of the competency movement of the past decade,” he said. “For smaller programs more reliant on interns for service, however, the new regulations will mean a need for providing nonresident clinical coverage by faculty and perhaps by nurse practitioners or physician assistants.”

Benjamin said some specialties, such as ob/gyn, and larger hospital systems have already begun moving toward round-the-clock physician attending coverage—a costly solution that will be untenable for smaller hospitals.

The ACGME task force was cochaired by E. Stephen Amis, M.D., who is chair of the ACGME Council of Review Committees and chair of the Department of Radiology at Albert Einstein College of Medicine and Montefiore Medical Center in New York; and Susan H. Day, M.D., outgoing chair of the ACGME Board of Directors and chair of the Department of Ophthalmology at California Pacific Medical Center, San Francisco.

In addition to physicians, the 16-member task force included three residents and a public representative. There were no psychiatrists on the task force.

A list of task force members and more information about the new standards and the Institutional Patient Safety and Quality Assurance review program are posted at <www.acgme.org>.