In light of new rules, residency programs review procedures

Residency programs are reviewing their operations after the Accreditation Council for Graduate Medical Education approved new rules governing how and when residents work.

Programs will have to ensure that residents get the most from their training in the time allotted, said Joanne Conroy, MD, chief health care officer of the Assn. of American Medical Colleges. Some will need to hire additional health care professionals, including nurse practitioners and physician assistants, to help manage the workload, she said.

The new ACGME standards will require residency programs to provide more supervision of the nation's 111,000 residents, educate them on the signs of sleep deprivation and revamp scheduling to minimize how often patients are transferred from one resident to another between shifts.

Most residents will continue to work up to 80 hours a week, averaged over four weeks, but first-year residents will be limited to 16-hour shifts. Other residents can work up to 24 hours plus an additional four hours for transferring patients.

"We're really going to have to manage our schedules, because at the end we have to deliver a resident who is actually skilled enough to manage that 24-hour schedule," Dr. Conroy said of first-year residents.

But the standards, which take effect July 2011, go beyond restricting the number of hours residents work, said Thomas Nasca, MD, ACGME chief executive officer. They emphasize maintaining training programs that educate, while protecting the safety of patients and residents.

"Duty hours are not in and of themselves as important as the other structural elements that we've introduced. We think this is a comprehensive package," he said.

ACGME's board of directors approved the standards Sept. 28 after 45 days of public comment last summer. They updated rules implemented seven years ago.

New rules raise concerns

But some say the standards don't go far enough.

"We're pretty disappointed with the final rules," said Charlie Preston, MD, MPH, a researcher with the Health Research Group at Public Citizen, a consumer advocacy organization. "They're not safe for the patients, and they're not safe for the residents who will take care of them."

Public Citizen was among several groups and individuals who submitted a petition to the Occupational Safety and Health Administration on Sept. 2. They asked the federal agency to take over regulation and oversight of resident work hours from the ACGME.

The petition asked OSHA to implement and enforce work-hour standards recommended in a December 2008 Institute of Medicine report, including maximum 16-hour shifts for all residents and a limit of 80 hours a week with no averaging.

OSHA responded with a Sept. 2 statement, saying the agency was "very concerned about medical students working extremely long hours," and endangering both themselves and patients. The agency had not released a decision on the petition as of this article's deadline.

The American Medical Association and the AAMC wrote to OSHA in support of the ACGME. In a Sept. 16 letter, AMA Executive Vice President and CEO Michael D. Maves, MD, MBA, said resident work standards must be governed by the profession, because only physicians can ensure the balance and flexibility needed to accommodate training for different disciplines.

This isn't the first time groups have asked OSHA to intervene on resident work hours. The agency denied a previous petition in 2002, citing ACGME as the appropriate authority to govern the issue.

During public comment on the standards, many respondents opposed the 16-hour restriction on first-year resident work shifts, saying it limited the development of residents' professionalism, Dr. Nasca said.

Jeff Wiese, MD, said the rules should address the amount of work residents must do during their shifts, rather than just the number of hours they can work.

"Medical errors are not so much a factor of how many hours a resident works, but the intensity of the work per hour," said Dr. Wiese, professor and associate dean of graduate medical education at Tulane University School of Medicine in New Orleans.

The standards were developed by a 16-member ACGME task force based on the 2008 IOM report, statements from medical organizations, testimony from more than 100 experts and a 16-month review of scientific studies on sleep issues, patient safety and resident training.

The standards are not set in stone, Dr. Nasca said, but will be reviewed and revised as needed.

"Graduate medical education will continue to be a skirmish point between public policy and professional self-regulation for some time into the future," he said. "Our obligation is to meet the needs of the public."