The AAFP and five other family medicine organizations have presented their views and recommendations on the latest proposals on residents' duty hours to the Accreditation Council on Graduate Medical Education, or ACGME. In a letter to the ACGME, the groups voiced particular concerns about proposals regarding the supervision of first-year residents and the 16-hour limit on interns' duty periods.
The groups recommend that the ACGME conduct pilot studies that examine different duty hour requirements and their effect on medical errors and patient safety guidelines. They also want the ACGME to publicly acknowledge the increases in program costs if the duty hour restrictions and other proposals are implemented.
The groups' letter comes in response to an ACGME request for comment on a draft of its new proposed duty hour standards(acgme-2010standards.org). The council's proposals followed a December 2008 Institute of Medicine report, Resident Duty Hours: Enhancing Sleep, Supervision and Safety(www.iom.edu).
In addition to the AAFP, the Association of Departments of Family Medicine, the Association of Family Medicine Administration, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group and the Society of Teachers of Family Medicine signed the Aug. 4 letter to ACGME CEO Thomas Nasca, M.D.
In general, the new proposals 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. They maintain work hours at a maximum of 80 hours per week, averaged over a four-week period, but call for significant changes in training, especially for first-year residents.
AAFP Board Chair Ted Epperly, M.D., of Boise, Idaho, who is program director and CEO of Family Medicine Residency of Idaho, praised the ACGME's efforts, telling AAFP News Now, "We recognize and appreciate the role the ACGME finds itself in as it tries to apply uniform standards of work hours across all of the nation's residency programs.
"The ACGME is trying to find the right balance between patient safety, avoiding excessive resident fatigue, excellent education and high-quality care. However, the restrictions at the PGY-1 (postgraduate year 1) level are excessive and will create a total reworking of many residency programs' infrastructure to accommodate these new proposed changes."
In their letter, the six organizations applaud items in the proposed new standards that they say are likely to result in positive change. One such item, they say, is language specific to resident education about fatigue-related issues, patient education, patient care, continuity/family relationships, teamwork, professionalism and accountability for physician/trainee safety.
The organizations also say the new requirements will encourage institutions to provide better resources to improve the quality of residents' education and certain aspects of their lives overall.
However, the letter describes the organizations' "multiple concerns" about the impact of the proposals on family medicine. Among them are concerns that the new limitations
- will decrease the overall educational time and clinical experiences for family medicine residents;
- will impair many programs' ability to meet the required continuity patient care visit thresholds in the ambulatory setting, thus compromising a key educational component of family physician training;
- are likely to promote a "shift work" approach to practice that is not consistent with efforts to move toward more patient-centered care; and
- could result in the need to extend family medicine training to 48 months, thus increasing costs and potentially hurting current efforts to recruit medical students to choose careers in primary care.
"These changes, if enacted fully and completely, may well be the tipping point of family medicine's seriously contemplating a move toward a four-year residency program to ensure that all the training needed to provide outstanding family physicians is accomplished," Epperly said of the proposals.
The organizations' letter notes that two proposed new standards, both involving first-year residents, are especially problematic. Those proposals state that
- all PGY-1 residents must be supervised either directly (physically present with resident and patient) or indirectly (physically within confines of site of care) with direct supervision immediately available; and
- duty periods of PGY-1 residents must not exceed 16 hours in duration.
The organizations object to the supervisory requirements because they relegate first-year residents "to the functional level of medical students by requiring excess levels of supervision."
"On July 1, when these residents become PGY-2s, however, they will be expected to not only function independently, but will be expected to be able to supervise PGY-1s, although they themselves will have no experience functioning in an unsupervised manner," says the letter
In addition, the organizations say the supervisory requirements have the potential to cripple small, community-based residency programs because of insufficient personnel to provide full patient care coverage.
Worse, according to results of a July 2010 survey of family medicine residency programs, the adoption of the proposed standards would threaten the existence of nearly 40 percent of programs with fewer than 22 residents.
"This is a big deal at a time in our nation's history when we need to be producing more family physicians for the good of our country's future workforce," Epperly told AAFP News Now.
In addition, the organizations say in their letter that the proposed 16-hour duty period limit for PGY-1s decreases these residents' ability to see the evolution of acute clinical disorders. It also adversely affects their ability to get required continuity training in ambulatory family medicine by limiting the number of patient care sessions in the family medicine center.
Moreover, they say the standard limits residents' availability to their patients both in the hospital and in the ambulatory setting, which will impact patient care negatively through increased hand-offs and transitions in care. In the July 2010 survey, 92 percent of program directors said this standard would negatively impact their programs.
In the letter, the six family medicine organizations make a number of recommendations. Those recommendations include calling for the ACGME to
- develop and implement pilot studies in which different duty hour requirements are measured against medical errors and patient safety guidelines;
- publicly acknowledge that the new duty hour restrictions will require an increase in training program faculty, with associated increases in program costs;
- better define the parameters under which duty hour violations trigger an accreditation review of the residency program; and
- develop educational materials for use by all graduate medical education programs to demonstrate a commitment to addressing the hazards of excess fatigue and sleep deprivation.
The final draft standards will be presented to the ACGME Board of Directors for their evaluation and approval next month. When finalized, the new standards will go into effect in July 2011.