Academy, Other Family Medicine Groups Oppose More Changes to Residents' Duty Hours

The AAFP and other family medicine groups have signaled their disagreement with recommendations made in a recent Institute of Medicine, or IOM, report that calls for additional restrictions on medical residents' duty hours and workloads as a way to minimize resident fatigue and maximize patient safety. If implemented, the groups say, the recommendations stand to hurt patient care while increasing medical training costs.

In a Feb. 3 letter to the Accreditation Council for Graduate Medical Education, or ACGME, the Academy and four other organizations representing family medicine said the IOM proposals to further shorten residents' work shift lengths and increase time off between shifts will result in more frequent patient hand-offs, raising the risk of medical errors and compromising continuity of care.

"What we're looking for is a balance of the right working conditions that maximize resident education and patient safety," AAFP President Ted Epperly, M.D., of Boise, Idaho, told AAFP News Now. The IOM recommendations "may be missing the mark by increasing patient risk through an increased number of hand-offs."

In 2003, the ACGME imposed its original duty hour limits, shortening residents' workweeks to 80 hours, averaged over four weeks, and setting a maximum shift length of 30 hours. The ACGME standards further break that maximum shift length into no more than 24 hours of "continuous on-site duty, including in-house call," with an additional six hours for transitional and educational activities.

The December 2008 IOM report, "Resident Duty Hours: Enhancing Sleep, Supervision and Safety," recommends keeping the total workweek hours at a maximum of 80. However, it diverges from the existing ACGME standards in recommending that, "Scheduled continuous duty periods must not exceed 16 hours unless a five-hour uninterrupted continuous sleep period is provided between 10 p.m. and 8 a.m."

After that sleep period, the IOM report adds, "a resident may continue the extended duty period up to a total of 30 hours, including any previous work time and the sleep period."

According to the Feb. 3 letter, "There (are) no data documenting that previous work restrictions have improved patient safety or that the benefits of further restrictions will outweigh harm from more frequent patient hand-offs."

In addition, the results of various sensitivity analyses (6-page PDF; About PDFs) projecting the likely financial impact of implementing the IOM report recommendations estimate that the cost of shifting resident work to other clinicians would be about $1.7 billion a year. Without more federal government support, these additional costs suggest an "unfair, unfunded mandate and an unreasonable expectation of the medical education community," the letter says.

The Academy did agree with the IOM's recommendation that both internal and external moonlighting factor into the 80-hour weekly limit, calling it a "potentially important step in minimizing resident fatigue."

The letter also included a number of recommendations to the ACGME, such as

The other signatories on the ACGME letter were the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the Society of Teachers of Family Medicine and the North American Primary Care Research Group.

According to Epperly, who is program director and CEO of the Family Medicine Residency of Idaho in Boise, all of the organizations that signed on to the letter "feel pretty strongly" that the IOM proposals will create more problems for residency directors without any guarantee that patient care will be enhanced. "We just need to find the right balance between maintaining patient safety and the complex process of educating residents and allowing them the work experience to be independent physicians," he said.

Judging from how the current ACGME duty hour standards have worked in his own program, Epperly added, "I'm not sure we're out of balance right now."

The ACGME will meet in March to discuss the IOM recommendations.