On March 10, the Accreditation Council for Graduate Medical Education (ACGME) released a final set of revised ACGME Common Program Requirements(www.acgmecommon.org) for learning and work environment professional standards for all accredited U.S. residency and fellowship programs.
The revisions, announced in an ACGME press release,(www.acgme.org) take effect on July 1.
According to the release, the revisions signify an about-face on the issue of clinical work hours (formerly referred to as duty hours) for first-year residents. The new requirements eliminate the 16-hour limit instituted some five years ago and return those residents to the 24-hour cap that has been in place nationwide for all other residents and fellows.
The revisions also allow residents as much as four additional hours (for a total of 28 hours) to achieve patient care transitions as necessary.
ACGME CEO Thomas Nasca, M.D., served as vice chair of the task force charged with revising section six of the program requirements -- work that that took nearly 18 months to finalize. In a memo made public on March 10,(www.acgme.org) Nasca stressed the key importance of the overarching goals embodied in the revisions.
- The Accreditation Council for Graduate Medical Education (ACGME) released a final set of revised Common Program Requirements for learning and work environment professional standards for all ACGME-accredited U.S. residency and fellowship programs.
- The revisions focus on patient safety, quality of care and physician well-being and return to the 24-hour cap on work hours for first-year residents.
- The new requirements mirror, in part, an AAFP policy on resident work hours adopted by the Academy's 2015 Congress of Delegates.
"At the heart of the new requirements is the philosophy that residency education must occur in a learning and working environment that fosters excellence in the safety and quality of care delivered to patients both today and in the future," he said.
Nasca noted the changes were supported by testimony from a "wide range of physician specialty educators" and were intended to
- emphasize patient safety and quality improvement,
- address physician well-being,
- strengthen team-based care, and
- allow residency programs flexibility in how they schedule clinical and educational work hours with established maximums.
He added that the ACGME conducts periodic reviews of all program requirements "to ensure that professional preparation of physicians adequately addresses the evolving and growing needs of patients."
Accordingly, a second task force is reviewing the remaining five sections of the Common Program Requirements; those revisions should be ready for implementation in July 2018.
New Requirement Highlights
The press release pointed out that the new requirements do not change residents' total clinical and educational hours. Rather, the standards state that programs and residents must adhere to maximum limits averaged over a four-week period. The revisions include
- counting work at home as part of the maximum of 80 hours per week,
- ensuring one day in seven is free of clinical experience or education,
- allowing in-house call no more frequently than every third night and
- permitting a maximum of 24 continuous work hours for all residents.
Furthermore, there is an emphasis on improving resident supervision when caring for patients, and optimizing the quality of care transitions and patient hand-offs. Research shows fewer hand-offs improve patient safety and continuity of care.
Importantly, with the increased flexibility provided in the revised program requirements, individual specialties can tighten up their requirements as needed and give residents and residency programs more discretion in how they structure clinical education.
Understanding that burnout and depression pose a significant risk to physicians, the new requirements -- for the first time -- make programs and institutions responsible for physician well-being.
"The 2017 revision includes a much-needed new section devoted to making the promotion of resident well-being a responsibility of both residency programs and the institutions that sponsor them," said Kim Burchiel, M.D., a task force co-chair and professor of neurological surgery at the Oregon Health & Science University School of Medicine in Portland.
"In many ways, this puts the ACGME at the forefront of combating physician burnout during residency training and, later, independent practice," she added.
The focus on patient safety is evidenced by new requirements that call on residents, fellows and faculty members to work with other health care professionals in "well-coordinated teams" that utilize shared methodology -- including reporting adverse events and unsafe conditions.
AAFP Response to Revisions
Stan Kozakowski, M.D., the AAFP's director of medical education, serves as the AAFP's liaison to the ACGME Review Committee for Family Medicine.
In that capacity, he attended the ACGME annual meeting March 10-12 in Orlando, Fla., where the revised Common Program Requirements were released.
He told AAFP News that he jotted down relevant phrases as various speakers provided their assessments of the new requirements.
"Flexibility is a shared responsibility," said one. "Residents have a responsibility to recognize the need to hand off patient care when they become too fatigued," said another. "Programs must work within the speed limit of an 80 hour-max work week," said a third.
And on the topic of supervision and accountability, one physician noted that "residents have a responsibility to arrive for work adequately rested and ready to care for patients."
Another acknowledged that there was "zero evidence" that patient safety improved when the 16-hour work limited was instituted.
For his part, Kozakowski came away from the ACGME announcement confident that the Common Program Requirement changes were a positive step. He noted that the requirements will continue to be reviewed in the future as a continuous improvement process.
"The success of medical training relies on the establishment of a covenant between learners and their programs and institutions," said Kozakowski. "The goal is to provide patients with safe and high-quality health care while simultaneously seeing that physicians-in-training receive a safe and superior educational experience. These revisions will help ensure both of those outcomes."
The AAFP Board of Directors first adopted a policy on resident work hours in 2002; that policy was updated by the AAFP Congress of Delegates in 2015.
AAFP policy specifies, among other things, that "Physicians have an ethical duty to their patients and profession to provide safe, compassionate, quality medical care. These duties depend on a safe and healthy working environment for resident physicians."
Related AAFP News Coverage
Leader Voices Blog: Time to Lift 16-Hour Limit on First-year Residents