New Duty-Hour Rules Present Challenges

As summer approaches, so does the start of new resident duty-hour regulations. On July 1, new guidelines governing residents' duty hours and requirements for supervision, which have been approved by the Accreditation Council for Graduate Medical Education (ACGME), take effect. In 2003, when the ACGME first issued resident duty-hour regulations, the standards were aimed at decreasing resident fatigue and sleep deprivation while improving patient safety.

Under the 2011 guidelines, residents will continue to be limited to the 80-hour duty week that was adopted in 2003. However, the length of continuous in-house duty for PGY-1 residents will now be limited to 16 hours, a change from the previous limit of 24 hours (with additional time allowed for educational activities or continuity of care).

Residents at the PGY-2 level and above will be allowed to continue to work for 24 continuous hours. Residency programs also will be required to include both internal and external moonlighting hours in a resident's overall tally of duty hours.

In addition to the work-hour limits, new requirements governing the supervision of PGY-1 residents have been delineated. A supervising physician must be physically present in the hospital, either working along with the resident or in-house while the resident is on duty. This new regulation for supervision of PGY-1 residents comes with a proviso that individual specialties can describe the competencies that PGY-1 residents must demonstrate before they can advance to working without in-house physician supervision.

In psychiatry, the following four key competencies are listed in the ACGME's guidelines for psychiatry training: demonstrating the willingness to ask for help when needed, gathering an appropriate history, performing an emergency psychiatric assessment, and presenting findings accurately to a supervisor.

Preparation for compliance with the new duty hours has presented both challenges and opportunities for psychiatry residency programs.

One of the greatest challenges is ensuring that the supervision and on-call responsibilities of residents, and especially PGY-1 residents, are compatible with the new duty hours. Residency programs have faced structural challenges in planning to comply with these requirements. Many programs have responded to the new requirements on PGY-1 residents by requiring from senior residents and faculty more frequent call and more responsibilities when on call. Programs with fewer residents may be unduly burdened by the new duty-hour regulations, given their limited capacity to absorb additional coverage needs.

Some physicians have voiced concerns about the potential for the adoption of a "shift mentality" among residents. And patient safety could potentially be compromised without detailed and reliable sign-out practices, particularly in acute psychiatric settings. Senior residents may find their continuity work in outpatient and other ambulatory settings disrupted by additional on-call duties, particularly in programs with night-float systems. In psychiatry it is particularly important that programs emphasize the crucial nature of the doctor-patient relationship and that residents uphold a sense of "ownership" for their patients while maintaining compliance with the new duty-hour standards.

Attempting to provide solutions to these challenges provides an opportunity for residents to engage constructively with faculty and residency programs to develop solutions that will enhance both residency education and patient care.

Residents who involve themselves in this process may gain valuable insights into the functioning and challenges of providing graduate medical education. The possibility of senior residents providing the necessary direct super vision to PGY-1 residents may also be a great opportunity for senior residents to develop teaching and supervisory skills. Many psychiatry programs lack the team structure that is common in departments of internal medicine and surgery, and the new supervisory requirements offer the opportunity to bring us closer to this model. This supervision would also improve social and academic interaction between junior and senior residents, especially in larger programs where this interaction may be more limited. Residents can contribute to development of a supervision program and educational curriculum for the incoming PGY-1 residents as they seek to progress to indirect supervision.

In our residency program at Emory University, residents have engaged with faculty in preparation for the transition to the new standards. We have worked jointly to create a residency environment in which education and patient care are paramount.

We urge residents to remain informed about the new duty-hour regulations and constructively voice their opinions as these standards are implemented. As residents, we are uniquely positioned to offer feedback on how the changes affect resident education and patient care. We must ensure that the generations of psychiatrists that follow us remain skilled physicians and that U.S. graduate medical education retains its international position as being in the vanguard of quality care and patient safety.