Residency directors express widespread concern about new work-hour rules

Residency program directors have significant concerns about how duty-hour standards that take effect in July will impact their ability to train residents, a new study says.

Eighty-seven percent of 464 program directors surveyed in July 2010 said the rules will lessen residents' ability to provide continuous care for hospitalized patients, and 65% said the rules won't have any effect on resident fatigue.

"The core of the issue for patients is what is it that we need to do in terms of working within these recommendations to achieve the very best outcomes for patients," said Darcy Reed, MD, MPH, senior study author and assistant professor at the Mayo Medical School in Rochester, Minn.

More than half of those surveyed said the rules will decrease residents' ability to become competent in five core areas: medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice, said the study in the March Mayo Clinic Proceedings.

The standards, approved by the Accreditation Council for Graduate Medical Education in September 2010, call for increased resident supervision, limiting first-year residents to 16-hour shifts, educating residents about sleep deprivation and revising schedules to minimize transfers of patient care.

By focusing on shift limits, the study ignored other key changes, including an increased focus on safety, residents' professional development, teamwork, alertness management and resident engagement to help improve quality of care, said Thomas J. Nasca, MD, ACGME's executive director and chief executive officer.

"These elements were added in response to input from experts in quality and safety, sleep physiology, fatigue mitigation, transitions of care, members of the committee that produced the Institute of Medicine's 2008 report, educators, the medical community and the public," he said.

More research needs to focus on the impact of work-hour standards and testing interventions that will enhance resident learning, Dr. Nasca said.

Moving forward

It's not surprising that the new rules present significant challenges for residency program directors, said Joanne Conroy, MD, chief health care officer of the Assn. of American Medical Colleges. Programs must make major changes in a short amount of time. Many will need to hire additional staff, reconfigure schedules and shift resources, she said.

"This is really an unfunded mandate," Dr. Conroy said. "Those specialties that require a lot of hands-on experience are particularly concerned."

Work hours are just one metric in evaluating graduate medical education, Paul H. Rockey, MD, MPH, director of the American Medical Association's division of graduate medical education, wrote in an accompanying editorial. Other key factors include quality of supervision, workload, hand-offs, work-life balance, teamwork, moonlighting and at-home call.

"Despite a tenuous link to the quality of patient care, resident hours have become the all-too convenient explanation for a variety of systemic ills and inefficiencies in health care," he wrote.

As a result, frequent rule revisions have made it difficult to evaluate the effectiveness of past changes. "The fundamental issue for GME is the successful formation of competent physicians and surgeons who are well-prepared to practice in their specialties without supervision," Dr. Rockey wrote.

Ethan D. Fried, MD, president of the Assn. of Program Directors in Internal Medicine, said that with innovation, information sharing and teamwork, program directors will adapt to the new rules just as they have to past changes.

"It could take a couple of years before people find the right pattern for their institution," he said.