The Accreditation Council for Graduate Medical Education, or ACGME, task force on resident physician training standards has released a draft of proposals(acgme-2010standards.org) that, among other things, provide more supervision of first-year residents, reduce first-year residents' duty periods to no more than 16 hours a day and set stricter requirements for duty hour exceptions.
The ACGME says in a June 23 press release(acgme-2010standards.org) that the proposals build on recommendations made by the Institute of Medicine in 2008. The proposals maintain work hours at a maximum of 80 per week, averaged over a four-week period but call for significant changes in training, especially for first-year residents.
"Patient safety and an excellent, humanistic learning environment are the ACGME's twin prime objectives," said Thomas Nasca, M.D., M.A.C.P., ACGME CEO and vice chair of the 16-member task force, in the press release. "The more closely the task force examined these related issues, the clearer it became that they were influenced by much more than just duty hours."
The draft standards were summarized in an article published online June 23 by the New England Journal of Medicine(content.nejm.org), or NEJM. According to the article, the draft standards "emphasize the importance of faculty supervision and teaching, improvement of the patient handover process and education of residents about how to manage alertness as part of their professional obligation."
The proposed 2010 ACGME requirements include the following:
- Three classifications of supervision -- direct supervision, indirect supervision and oversight -- would be set. First-year residents, for example, must have direct supervision, in which the supervising physician is physically present and overseeing the resident's activities, or indirect supervision, in which the supervising physician is on-site.
- Workloads for each resident are to be set based on level of training, patient safety, resident education, severity and complexity of patient illness, and available support services.
- Duty periods for first-year residents are to be no longer than 16 hours a day. Residents in postgraduate year two or greater may continue to be scheduled for a maximum of 24 hours of continuous duty.
- Residents would be allowed to remain on-site for no longer than an additional four hours to provide for the transfer of care. They may not, however, attend continuity clinics after 24 hours of duty.
- Inhospital on-call frequency would be set for every third night, with no averaging, for residents in postgraduate year two or greater.
- First-year residents would be required to have a minimum of eight hours free of duty between scheduled duty periods. Similar provisions are included for residents in postgraduate year two or greater and for residents in their final year of training. Residency review committees, however, may permit certain exceptions.
- Residents would not be scheduled for more than six consecutive nights of "night float."
- Internal and external moonlighting would be included in the 80-hour work week limit. First-year residents, however, would not be permitted to moonlight at all.
According to the NEJM article, the hours of first-year residents are more restricted and they are more closely supervised because "first-year residents have longer work hours than any other cohort of residents." In addition, it says, scientific evidence shows that "fatigue affects the frequency of errors committed by first-year residents."
As residents gain knowledge and experience and expand their clinical judgment capabilities, the standards permit them to move from a structured, directly supervised, time-limited setting to more advanced training and, finally, to the independent practice of medicine.
According to the article, the ACGME's new standards "will enhance the quality and safety of patient care in teaching hospitals, meet the clinical educational needs of residents, and benefit the future quality and safety of care when residents trained under the new standards enter independent practice."
The proposed standards are available for comment until Aug. 9 on the ACGME website.