New Rules May Mean Fewer Hours for Interns and Residents

The Accreditation Council for Graduate Medical Education (ACGME) has released a comprehensive proposal for revision of the 2003 resident standards, revisions that, if enacted, would set stricter duty hour limits and provide more specific directives for levels of supervision.

According to an article about the proposed revisions published in the New England Journal of Medicine (NEJM), the current standards for residents have three “particularly problematic” elements: “First, the duty-hour limits may have created or exacerbated the adoption of a "shift mentality" during residency. This attitude may conflict with physicians' moral and professional responsibility to their patients and may leave residents unfamiliar with and unprepared for the hours and professional obligations of practicing physicians. Second, duty hours remained the primary focus for programs and institutions; larger changes in the learning environment that were envisioned when the duty-hour standards were instituted in 2003 never materialized. Third, the current limit on continuous duty is the subject of intensive debate, with lingering concerns that it may leave residents susceptible to the effects of acute sleep loss.”

To address these issues, the proposed requirements would “specify more detailed directives for levels of supervision necessary for a first-year resident (known as a PGY-1) vs. more experienced residents, reduce duty periods of first-year residents to no more than 16 hours a day,” and “set stricter requirements for duty hour exceptions.”

The proposal also addresses teamwork, clinical responsibilities, and transitions of care. New requirements in these areas would:

“- Establish graduated requirements for minimum time off between scheduled duty periods.

- Expand program and institutional requirements regarding handovers of patient care.

- Set more specific requirements for alertness management and fatigue mitigation strategies, designed to ensure both continuity of patient care and resident safety.”

“Patient safety and an excellent, humanistic learning environment are the ACGME's twin prime objectives,” said Thomas Nasca, MD, MACP, chief executive officer of ACGME and vice chair of the task force. “The more closely the task force examined these related issues, the clearer it became that they were influenced by much more than just duty hours. And we recognized that a ‘one size fits all' set of standards didn't make sense.”

Nasca continued: “In revisiting resident training standards the task force considered many issues, not just duty hours, that can spark an emotional response. Our process strove to strip away the emotion and evaluate the available scientific data to make the proposed new standards as evidence-based as possible."

HCPLive wants to know:

What do you think? Do the new rules go far enough in protecting against doctor fatigue? Or will they end up needlessly raising costs, depriving residents of important training, and hurting patients who are handed off from doctor to doctor as shifts end?

What did you learn from your own extended shifts as a resident? Were they a key element of your training or a dangerous exercise in practicing medicine while exhausted?

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