October 2002
Volume 66 |
Number 10
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RESIDENTS' REVIEW
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New Work Limitations Give Residents
a Break
Jill H. Mhyre,
M.D.
"Residents' Review" Co-editor
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In June, the Accreditation Council for Graduate Medical
Education (ACGME) made recommendations for limitations of
resident work hours to be implemented in July 2003. The
move to control work hours follows a long political action
campaign stressing the increase of patient acuity, resident
stress and a growing body of literature that documents the
negative impact of extreme fatigue. It also follows the
precedent of other professions – truckers are permitted
by the federal government to drive only 60 hours per week
and airline pilots to fly just 34 hours per week.1
Currently limits on resident duty hours are made by the
individual specialty Residency Review Committees (RRCs).
Anesthesiology already limits resident shifts and is well
on its way to compliance with the new ACGME guidelines.
In 1999-00, only 2 percent of anesthesiology programs were
cited by ACGME for work hour violations as compared with
up to 35 percent of general surgery residency programs.2
The current requirements of the anesthesiology RRC with
regards to duty hours include: One full day out of seven
free of program duties; on average, being on call no more
than every third night; and residents do not administer
anesthesia on the day after in-house overnight call. The
anesthesiology RRC guidelines place most anesthesiology
programs well along the way toward ACGME compliance.3
The new ACGME requirements duplicate the anesthesiology
requirements but allow averaging to take place over a four-week
period: One day in seven free of patient care responsibilities
averaged over a four-week period; in-house call no more
frequently than every third night, averaged over a four-week
period; and a 24-hour limit on in-house duty call with an
added period of up to six hours for patient continuity and
transfer of care.
In addition, ACGME specifies that a 10-hour minimum rest
period should be provided between duty periods and that
residents must not be scheduled for more than 80 duty hours
per week, averaged over a four-week period, with the ability
to apply for an increase of up to 88 hours per week if justified
by a sound educational rationale.4
To promote adherence, ACGME has placed responsibility for
oversight and monitoring of duty hours with the residency
institutions. ACGME will provide information on sleep deprivation
and suggestions on ways to meet service demands with fewer
residents. Penalties imposed by ACGME would be linked to
accreditation. On average, each accredited residency program
is reviewed by ACGME every 3.7 years.5
The Patient and Physician Safety and Protection Act (PPSPA)
was introduced to Congress by John Conyers (D-MI) in November
2001 and to the Senate by Jon Corzine (D-NJ) in June 2002.
The political pressure created by the PPSPA may have helped
encourage ACGME to create its own guidelines. If passed
into federal law, the PPSPA would remove four-week averaging
so that no resident would work more than 80 hours per week
or 24 hours at a time. In addition, the PPSPA would create
a national anonymous-reporting mechanism for house officers
to report excess work hours. Hospitals violating the rule
would face civil penalties as well as reductions in Medicare
funding. The bill also would provide national funding to
assist hospitals with hiring additional staff needed to
relieve residents of the burden of noneducational activities.
Joel Segal from Representative Conyers Washington office
said: "The ACGME and the [American Medical Association]
should be commended for taking responsibility and moving
in the right direction with resident physician work hours.
Congressman John Conyers will continue to pursue this legislation
while watching to see if the ACGME guidelines alone can
create an environment that better balances resident education
with patient safety."6
Several unanswered questions remain. While the new ACGME
guidelines should impact most anesthesiology programs less
than training programs in other disciplines, their implementation
will likely require small scheduling changes. The impact
on other residents could, however, be greater and impact
us indirectly. For example, more surgeries may be performed
by attending surgeons and physician assistants without surgical
resident involvement, and the current system, which relies
heavily on residents in both anesthesiology and surgery
to "grease the wheels," would be outdated. Another
uncertainty is whether the PPSPA will pass in Congress,
and if so, what impact this will have on anesthesiology
training.
References:
1. < www.house.gov/conyers/news_patientsafetyprtectionact
.htm >.
2. < www.acgme.org/new/dutyhrscompare.pdf
>.
3. American Medical Association Graduate
Medical Education Directory 2001-2002: 48.
4. < www.acgme.org/new/residentHours602.asp
>.
5. < www.acgme.org/
> .
6. In a conversation with Joel Segal in
September 2002.
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Jill
M. Mhyre, M.D., is a CA-2 anesthesiology resident at
the University of Michigan, Ann Arbor, Michigan. |
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