Residency programs scramble to adopt changes

New ACGME rules require fewer work hours, increased supervision and a renewed emphasis on quality.

By — Posted July 11, 2011

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

Residency programs nationwide worked fast to implement new Accreditation Council for Graduate Medical Education rules governing residency training that took effect July 1.

The standards, approved by the ACGME in September 2010, call for a variety of changes. They include increased resident supervision, limiting first-year residents to 16-hour shifts, educating residents and faculty about sleep deprivation, and ensuring effective transfers of patient care.


Dr. Bready

Many programs had to scramble to make the changes in time, said Joanne Conroy, MD, chief health care officer with the Assn. of American Medical Colleges.

"We're hearing from all of them that the timeline has been short," she said. "They would have preferred to have had another year."

The changes were more of a challenge for smaller programs, said Thomas Nasca, MD, executive director and CEO of ACGME.

He visited about a dozen academic medical centers this spring that represent more than 100 residency programs. Most had implemented the rules. Some smaller institutions ran into trouble because the changes require them to expand their staffs to make up for reduced first-year resident shifts, he said.

Challenges of change

Dr. Conroy said the AAMC has heard from many hospital CEOs concerned about costs associated with the changes, such as hiring more staff and separating teaching and nonteaching services.

Residency directors face a variety of challenges, such as how to provide the best education for residents within new limits and how to prepare interns for a second year oriented around 24-hour shifts, Dr. Conroy said.



"All of a sudden there is a dose of reality when you have to retool the way you provide care," she said.

At the University of Texas Health Science Center at San Antonio, which has about 80 GME programs and 750 residents and fellows, changes will cost about $3.5 million annually, said Lois Bready, MD, an anesthesiologist and senior associate dean for GME.

It's difficult to find new funding in tight economic times, but the result will be worthwhile, she said. The new rules already have led to innovative programs at UTHSCSA, such as educational programs on fatigue management and working as an effective health care team.

"It's a process in evolution," said Dr. Bready, who served on the ACGME rules review committee. "This has been from the get-go an issue with dual goals -- safe patient care now, at the same time providing quality training for residents so we'll have safe patient care 10, 20, 30 years down the road."

Not far enough?

But some say the ACGME regulations don't do enough to protect patients and residents.

"The American Medical Student Assn. feels that they haven't made the rules nearly stringent enough," said Sonia Lazreg, a health justice fellow with AMSA and the Committee of Interns and Residents.

AMSA was among several groups and individuals who petitioned the Occupational Safety and Health Administration on Sept. 2, 2010, to take over regulation and oversight of resident work hours from the ACGME. OSHA is considering the petition, Lazreg said.

Organizations such as the AAMC and the American Medical Association responded by voicing support for the ACGME. At its Annual Meeting in June, the AMA adopted a policy to continue monitoring the effects of the ACGME rules and supporting the medical profession's right to govern itself.

In a June 24 article in Nature and Science of Sleep, five experts in sleep, patient safety and health policy, including two who signed the OSHA petition, outline how institutions can adopt recommendations made in a December 2008 Institute of Medicine report. The article was written after a Harvard Medical School conference of 26 professionals invited to participate June 17-18, 2010, before the ACGME rules were approved.

Key to instituting the IOM recommendations is altering the workload to ensure that residents get the best educational experience, said Alexander Blum, MD, the article's lead author and a health policy fellow at Mount Sinai School of Medicine in New York City.

"A lot of what residents do has no educational value, such as filling out paperwork, double-checking prescriptions or calling and making appointments for patients," Dr. Blum said.

The ACGME rules ignore the IOM's recommendation that no resident work more than 16 hours at a time, said Lucian Leape, MD, article co-author and adjunct professor at Harvard School of Public Health. Residents in their second year and above work up to 24-hour shifts with an additional four hours to manage transitions in care.

"The assumption there is that you can learn to tolerate sleep deprivation," Dr. Leape said. "What we are seeing here is a massive denial of the evidence. The evidence is that patients are being harmed by residents having to stay up all night."

But the AAMC's Dr. Conroy said there's much debate in the medical community about what the research shows, and that the ACGME's rules go far beyond shift limits.

"It's interesting how people concentrate solely on the numbers when there is so much more to patient safety and quality than the hours that people work," Dr. Nasca said.

Back to top


New rules for residents

The Accreditation Council for Graduate Medical Education's latest regulations for residency programs took effect July 1, updating its 2003 standards. The ACGME will begin annual reviews of institutions in July 2012. The rules include:

  • First-year residents work a maximum of 16 hours. Other residents work up to 24 hours at once, with an additional four hours to manage transitions in care.
  • Residents are limited to 80 hours per week, averaged over four weeks and including all moonlighting.
  • Residents must participate in interdisciplinary clinical quality improvement and patient safety programs.
  • Clinical assignments must be designed to minimize transitions in patient care, and residents must be competent in communicating with team members in handoffs.
  • Residents must have three levels of supervision, with a physician available to provide direct supervision for first-year residents at all times as needed.
  • Faculty and residents must be trained to recognize sleep deprivation, and programs must have processes to manage fatigue, such as naps or back-up call schedules.
  • Institutions must provide sleep facilities and/or safe transportation options for fatigued residents.

Source: Accreditation Council for Graduate Medical Education (link)

Back to top

External links

Accreditation Council for Graduate Medical Education duty hours (link)

"Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision and safety," Nature and Science of Sleep, June (link)

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn