After the Accreditation Council for Graduate Medical Education, or ACGME, approved new resident duty hour limits that especially affect first-year residents, Academy leaders and family medicine program directors are concerned that upper-level residents and faculty will shoulder too much of the workload and associated added expenses will force the closing of small programs. Moreover, they say, patient safety -- the original aim of the new restrictions -- may not necessarily be enhanced.
Perry Pugno, M.D., M.P.H., director of the AAFP Division of Medical Education, told AAFP News Now that the new duty hour requirements disproportionately affect family medicine residencies at a time when the nation's need for more primary care physicians could not be more extensive.
The new duty hour limits "put our currently financially stressed programs at risk," Pugno said. "It will boil down to a need for more resources to meet the new requirements."
Joseph Gravel, M.D., of Lawrence, Mass., president of the Association of Family Medicine Residency Directors, agreed. "If there were a clear cause-and-effect (relationship), and these new requirements would improve patient safety, program directors would be in full support of all the rules. But the concern is that they would decrease resident training time, and we risk graduating less well-trained physicians. And this could hurt patient safety rather than improve it."
After months of testimony, hearings and public comment, the ACGME approved the new Common Program Requirements(acgme-2010standards.org) on Sept. 26. They will become effective for the nation's 111,000 residents in July 2011.
The rules maintain work hours at a maximum of 80 per week, averaged over a four-week period, but there are significant changes for interns, or first-year residents. Among them are the following:
- First-year residents will work no longer than 16 hours a day. Upper-level residents may continue to be scheduled for a maximum of 24 hours of continuous duty.
- There will be three classifications of supervision: direct supervision, indirect supervision and oversight. First-year physicians must have direct supervision in which the supervising physician is physically present and overseeing the resident's activities, or indirect supervision, in which the supervising physician is on-site.
Gravel is program director of the Lawrence Family Medicine Residency in Lawrence, Mass., which is a federally qualified health center with 26 residents. He said his biggest concerns are the 16-hour work limit for first-year residents and how it will affect his program's ability to ensure adequate graded responsibility and adequate supervision at the same time.
As a result of the changes, upper-level residents and faculty members in his residency may need to shoulder more of the work responsibilities, Gravel said. That, in turn, could mean additional faculty would need to be hired, increasing program costs without additional resources from Medicare.
"All program directors are in favor of adequate supervision, of safe practice, of quality education. But some of the provisions will most likely have the unintended consequence of closing some programs," he said.
Benjamin Schneider, M.D., a third-year resident in the Family Medicine Residency Program at Oregon Health & Science University in Portland and the resident representative to the Association of Family Medicine Residency Directors Board of Directors, recently shared his thoughts about the new resident duty hour limits with AAFP News Now. Read what Schneider has to say on this topic.
Other directors of small residency programs said they are discussing ways to accommodate the duty hour changes with limited resources.
Geoffrey Jones, M.D., is program director of the Mountain Area Health Education Center Family Medicine Residency in Hendersonville, N.C. The small program in rural Southwestern North Carolina has nine residents.
"We presently rely on first-year residents to take call in our program," Jones said. "We will have to add to the faculty workload with in-house call and cover our patient service without a resident regularly. We will certainly have many more hand-offs than we have now, which is definitely going to create opportunities for mistakes in communication.
"I think the interns will probably benefit from more hands-on supervision, but they may also suffer from not having an opportunity to figure things out for themselves first. The interns will also not gain the experience they currently do because many educational moments will happen during the eight to 10 hours they are off every night."
Jones said his program is investigating using nearby Pardee Hospital's inpatient hospitalist group to provide in-house supervision, or it may cover interns' overnight hospital shifts with faculty only. Either accommodation would require additional funding at a time of economic uncertainty, he said.
"With only nine residents in a small community hospital, we do not have the manpower to easily accommodate these changes. I also worry that the educational experience will not be sufficient over three years to graduate the same caliber of resident that we have in the past."
Stephen Salanski, M.D., program director of the Research Family Medicine Residency in Kansas City, Mo., said the changes also will affect his larger program, which has 39 residents.
Because the program uses a night float system, call will not change much for the first-year residents. But to meet the new supervision requirements, upper-level residents and faculty who have been taking call from home will have to take in-house call to supervise the first-year residents.
Salanski said the supervision problem is likely to get worse because the new requirements suggest "strategic napping" after upper-level residents work 16 hours --which will require additional call coverage during that time. Salanski said another third-year resident or a faculty member would need to provide this coverage.
In addition, he noted, residents also will have a difficult time meeting required continuity clinic visits. Currently, after 24 hours in the hospital, residents still can go to the continuity clinic the following morning. Under the new rules, they won't be able to see patients in the continuity clinic and will lose eight to 10 patient visits per missed clinic session.
Smaller community-based residency programs may feel the brunt of the changes, but directors of university-based programs foresee less of an impact.
For Daniel Burke, M.D., program director of the University of Colorado Family Medicine Residency in Denver, the new requirements will affect scheduling of residents in the continuity clinic only minimally.
Inpatient rotations already are concentrated into the first half of the residency, he said, which leaves the last half to reliably schedule residents, including first-year residents, for the clinic. Even the 16-hour work limit on interns won't have much effect on their service or education, he said.
"When they're on call, we'll have them start at about 6 p.m. instead of in the morning. That way they can stay until mid-morning the next day and get a sense of how the patient looks with the care they instituted the previous evening," Burke said.