Respect the spirit -- and the letter -- of resident work hour standards, say RAP speakers -- May 2003 -- FP Report

Respect the spirit -- and the letter -- of resident work hour standards, say RAP speakers

BY CINDY McCANSE BORGMEYER

Residents, July 1 is probably already marked on your calendar. But if it's not, you might want to consider noting it. That's the deadline to comply with resident work hours standards issued in February by the Accreditation Council for Graduate Medical Education.

Understandably, the standards were one of the hot topics at this year's Residency Assistance Program Workshop for Faculty and Staff of Family Practice Residencies March 31 in Kansas City, Mo. A presentation by Richard Viken, M.D., professor and family medicine department chair at the University of Texas Health Center at Tyler, and Scott Lawrence, M.D., also on the health center faculty, focused on key elements of the standards.

The two presenters first laid out some of the basics of the ACGME guidance, and then followed up with questions for participants to weigh in on. Here's a rundown:

Residents are limited to an 80-hour workweek averaged over four weeks. Residency programs may apply to the residency review committee for their specialty for permission to increase residents' duty hours up to 10 percent over that cap, but they must present a compelling educational rationale to do so. And gaining that approval is by no means a given.

As for family practice programs vying for such an exception -- "Forget it," Viken flatly declared. "There's no way the RRC for Family Practice will honor any 10 percent increase."

In-house duty periods may be no longer than 24 consecutive hours, although residents may remain on duty an additional six hours to hand patients off to new care teams, maintain continuity of care or participate in educational activities. Keep in mind, Viken said, that included in this 24-hour period is anything done in-house, including sleeping and eating.
A 10-hour minimum rest period, free from mandated educational or patient care duties, should be provided between duty periods.
Residents are due one full day -- yes, that's 24 hours -- out of every seven free from patient care responsibilities, averaged over four weeks.
In-house call is limited to no more than once every third night, again averaged over four weeks. And don't even try to buck the system by shifting the yeoman's share of call to at-home rather than in-house: The RRCs are looking for it and will call you on it, Viken warned.

"We, as program directors, have to avoid the trap of scheduling people for at-home call on a regular basis because of the possibility that they'll wind up coming in all the time," he said. Once that resident sets foot inside the facility, the 80-hour clock starts.

What's important to remember, said Lawrence, is keeping to the spirit, as well as the letter, of the standards. Ultimately, it's the residency's responsibility to assess each resident's fatigue level, with a goal of ensuring both the safety of the resident and that of the resident's patients.

The ACGME standards are quite similar to AAFP policy on resident work hours established by the Commission on Education and Commission on Resident and Student Issues more than a year ago.

To read the full text of the standards, go to http://www.acgme.org/dutyhours/dutyhourslang_final.asp. A news release about them is at http://www.acgme.org/media/dutyhoursrelease.pdf, and you can visit http://www.acgme.org/dutyhours/dhfaqs.pdf for answers to frequently asked questions about implementing them. Information about accessing and reading PDF files is at http://www.aafp.org/pdf.xml.

To reach writer Cindy McCanse Borgmeyer, e-mail cborgmey@aafp.org.

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