AFMRD Survey Findings

More Limits on Resident Duty Hours Would Have 'Detrimental' Effect, Say Program Directors

February 03, 2010 05:15 pm Barbara Bein

A majority of family medicine residency program directors who participated in a recent survey do not think proposals from the Institute of Medicine, or IOM, to further restrict resident duty hours will result in improved patient safety and resident education. In fact, according to a study co-authored by an AAFP workforce expert and others involved in family medicine education, the program directors think the proposals, if implemented, would have detrimental effects in both of those areas.

Specifically, more than 71 percent of program directors who completed the survey said they disagreed or strongly disagreed that the proposed IOM duty hour recommendations, if enacted, would result in improved patient safety. More than 87 percent disagreed or strongly disagreed that the recommendations would result in improved resident education.

"Most program directors have already seen -- and expressed concern about -- a decline in the overall engagement with, and concern for, their patients among some of today's physicians-in-training, coincident with further restrictions in duty hours," said Perry Pugno, M.D., M.P.H., director of the AAFP Division of Medical Education and one of the co-authors of the study. "In fact, this appears to be a global problem among physicians-in-training whose work hours are being limited by regulatory bodies."

Jay Fetter, M.S.A., EVP of the Association of Family Medicine Residency Directors, or AFMRD, and another study co-author, said it's important to heed program directors' concerns -- on the duty hours question, as well as on other issues.

"Program directors are uniquely positioned to directly observe the impact of changes in health care," he told AAFP News Now. "Regulatory changes and even generational shifts often play out first in the learning/care environment of a residency program."

The results of the survey(, "Impact of Proposed Institute of Medicine Duty Hours: Family Medicine Residency Directors' Perspective," were published in the December 2009 issue of the Journal of Graduate Medical Education, the new peer-reviewed journal of the Accreditation Council on Graduate Medical Education, or ACGME.

Report Sparks Concerns About Safety and Quality

The survey comes in the wake of a December 2008 IOM report( that recommended residents' work hours be kept at a maximum of 80 hours per week, averaged during a four-week period, as set by the ACGME in 2003. But the IOM made several other recommendations in its report, including recommending that residents' duty shifts should not exceed 16 hours of continuous work and that the maximum shift length of 30 hours must be broken up by an uninterrupted five-hour sleep period between 10 p.m. and 8 a.m.

The AAFP and four other primary care organizations subsequently said in a letter to the ACGME that such additional restrictions would result in more frequent patient hand-offs, raising the risk of medical errors and compromising continuity of care. (Then) AAFP President Ted Epperly, M.D., of Boise, Idaho, delivered a similar message when he testified before the ACGME National Congress on Duty Hours last June.

Then, at the 2009 interim meeting of the AMA House of Delegates in November, delegates adopted a medical education council report that directed the AMA to call for further research into protected sleep periods during prolonged in-house call and to encourage the ACGME to not adopt the IOM report's proposed new duty hour limits.

Now, family medicine residency directors have added their voices to the debate. Of the 435 surveys sent to family medicine residency program directors, 265 surveys were completed, for an almost 61 percent response rate.

Program Directors Largely Dispute IOM Assertions

In addition to disagreeing with the IOM's contention that added duty hour restrictions would enhance patient safety and resident education, more than 71 percent of the program directors said implementation would result in decreased access to care.

With regard to medical education, almost 91 percent of respondents agreed or strongly agreed that they were concerned that residents are developing a "shift-worker" mentality that the IOM rules would only exacerbate. In addition, almost 84 percent said they thought the rules would result in graduating doctors who are not experienced enough to practice independently; almost 93 percent said they thought the graduating doctors would take less "ownership" for the care of their patients; and almost 91 percent said the new physicians would be less prepared for the work hour demands of future practice.

Moreover, almost 84 percent disagreed or strongly disagreed that the proposed IOM rules would result in residents becoming more compassionate and more effective family physicians.

The program directors' responses illustrate a major concern among medical educators about the proposed new duty hour restrictions, said Pugno -- namely, that "new residency graduates risk completing training with inadequate experience to guarantee competency and without the dedication to those they serve that the profession and patients expect of them."