Duty Hour Changes Hit One-year Mark

Medical Residents Sound Off About New ACGME Rules in National Survey

August 17, 2012 03:40 pm Sheri Porter
[Stock photo-Four female doctors talking]

Many medical residents do not believe that new rules(acgme-2010standards.org) implemented by the Accreditation Council for Graduate Medical Education's (ACGME's) Duty Hours Task Force in July 2011, have had the intended effect, according to a recent survey(www.nejm.org) in the New England Journal of Medicine.

In fact, nearly half (48.4 percent) of residents who responded to the survey disapprove of the overall rules in the ACGME's Common Program Requirements; only 22.9 percent approve of the rules, which were intended to improve patient care, resident education and resident quality of life.

More than 120 institutions in 41 states agreed to distribute the survey to their residents. Data were collected for a 12-week period beginning in February 2012. Researchers received 6,202 individual responses, and primary care was well represented with family medicine, internal medicine and pediatric residents topping the list in numbers of responses received.

The survey posed 12 questions about the new rules to residents and asked for a positive, neutral or negative response. Resident responses helped compile statistics that show, among other things, that

  • 51.5 percent of respondents thought that the new rules made preparation for a more senior role worse;
  • 49.7 percent of residents said quality of life for senior residents was worse;
  • 43.0 percent believed work schedules were worse, but 30.1 percent said they were better;
  • 40.8 percent of residents indicated that the quality of education was worse, and 42.8 percent said it was unchanged; and
  • 27.0 percent of respondents thought safety of patient care was worse, 52.6 percent said it was unchanged and 20.4 percent said it was better.
Story Highlights

  • A survey in the New England Journal of Medicine reports on how residents perceive changes in program requirements implemented by the ACGME one year ago.
  • Among other things, the new rules changed the quality and quantity of hours worked and increased supervision of residents at teaching hospitals.
  • Nearly half of resident respondents disapprove of the new rules overall; about 30 percent approve.
  • Some family medicine program directors also think some rules do not have the intended effect of benefitting residents and patients.

In terms of rolling out the new regulations, tracking and documenting residents' hours to ensure that the program is not in violation of rules has been an issue, according to Grant Hoekzema, M.D., program director at Mercy Family Medicine Residency Program in St. Louis. "We require clocking in and out of work, and this is not a habit or behavior most residents envisioned when entering medical school, so subsequently, they forget," said Hoekzema.

The new regulations stipulate that first-year residents (interns) spend no longer than 16 consecutive hours in the hospital and can only work 6 consecutive days. Senior residents, however, can be scheduled for a maximum of 24 continuous hours on duty.

Hoekzema said the change in duty hours was "playing havoc" with patient continuity. Patients who call the office and want to talk to their doctor "often find them off duty or unavailable. This makes it tough for residents and patients alike to form bonds that will tie them together during those three (residency) years," said Hoekzema.

Karen Mitchell, M.D., program director at Providence Family Medicine Residency in Southfield, Mich., said her program had to make just one change when the new rules took effect. "We used to have first-year residents stay overnight once on a Friday night during their inpatient month," said Mitchell. "But we had to change that because of the 16-hour rule."

Although Mitchell's first-year residents still get some of that night-time call experience with senior supervision, it's more disruptive and requires more handoffs than what they did with an overnight Friday because interns can't come in during those days, according to Mitchell.

Patient handoffs also have been an issue for Stoney Abercrombie, M.D., program director at the AnMed Health Family Medicine Residency Program in Anderson, S.C. "We've had to work much harder to be sure that the handoffs are formalized and written, not just verbal," he said.

Abercrombie said he's also hearing from his second- and third-year residents that it's hard to be on night float for a week or two at a stretch and get enough sleep during the day. "It's like being shift workers in that it's hard to get your sleep pattern set," he said.

He acknowledged that a better-rested resident physician should lead to enhanced patient care and safety, but he wonders if residents really are catching up on their sleep during the day or just catching up on life.

Abercrombie said he works hard to ensure that residents who are on several weeks of night duty and can't come in for daytime lectures and conferences have access to online studies and recorded lectures. "There's more asynchronous education going on," he said.

The education of interns also is in jeopardy when they aren't allowed to serve 24-hour shifts, said Abercrombie. A lot of the work has been shifted to the upper levels, and that fact has not been lost on the senior residents who muse -- sometimes aloud -- if the interns will be prepared to step into senior residents' shoes, a concern that Abercrombie shares.

Michael Tuggy, M.D., program director at Swedish Family Medicine Residency in Seattle, hears comments from the senior residents about quality-of-life issues.

"They are not working more hours but a few longer stretches," said Tuggy. "The quality of life for senior residents feels like it has gotten worse because they get pulled in for 24-hour shifts where interns are restricted to 16." Tuggy added that he's seen more than a few disdainful eye rolls from residents at mention of the interns' lighter shift work.

With all the negatives brought about by the new regulations, including less continuity, increased handoffs and educational gaps, Tuggy wonders if perhaps the whole issue of duty hours has been overregulated. "Duty hours are meant to protect residents, but the more restrictive hours become, the less time there is for patient care that enables residents to get the experience they need," he said. "It seems like they (ACGME) could eliminate some things that aren't that critical."