AAMC Reporter: January 2009

Medical Education, Accreditation Officials Reach to Resident Duty Hours Report

Related Resources Five Years Later, Resident Hours Limits Still Debated—Reporter, July 2007 Group on Resident Affairs (GRA) Resident Duty Hours: Enhancing Sleep, Supervision, and Safety (Institute of Medicine) ACGME's Effort to Address Resident Duty Hours (Accreditation Council for Graduate Medical Education)

A recently released Institute of Medicine (IOM) report is calling for medical educators and stakeholders to revise residents' length of continuous training, supervision, and workloads to improve patient safety and trainee learning.

The report, "Resident Duty Hours: Enhancing Sleep, Supervision, and Safety," comes five years after the Accreditation Council for Graduate Medical Education (ACGME) instituted resident duty hours regulations, capping training at 80 hours per week. Although the IOM report does not suggest changing the 80-hour limit, it does recommend reducing resident shift times to 16 hours, or mandating five hours of sleep in a 30-hour maximum period of continuous duty. Compulsory time off should increase from four to five days per month, and residents should have one day off every week and 48 consecutive hours off once a month, the report states.

"The sleep literature makes it clear that fatigue increases the chances of committing errors," said Michael Johns, M.D., report committee chair and chancellor of Emory University. "Altering duty hours is an important step, but it is not enough to maximize patient safety."

AAMC President and CEO Darrell G. Kirch, M.D., commended the report committee, comprised of patient safety experts and medical educators, for its comprehensive review.

"We agree with the IOM that we must examine duty hours as one of many factors in patient safety and quality of care," said Kirch, in a statement. "Resident trainees must engage in sufficient and appropriate clinical activities across the continuum of patient care to ensure that they develop into physicians capable of independently practicing safe, high-quality medicine."

In addition to the hours recommendations, the IOM report calls for clearer communication during handovers, the procedure by which residents transfer patient care responsibilities at the end of a shift. According to the report, trainees' schedules should overlap during shift changes to improve communication and facilitate smooth handovers.

The report also recommends more monitoring to ensure compliance with duty hour regulations. Residency review committees, which examine the GME programs of particular medical disciplines, should create standards of supervision for residents at each training level, the report states.

The report recommended that stakeholders act on all suggestions within 24 months.

Linda Famiglio, M.D., chief academic officer at Geisinger Health System in Danville, Pa., was pleased that the report "did not focus solely on the number of hours that residents train," but was hoping for more flexibility in the rule requiring a five-hour break between shifts.

"Five hours is a complete session of sleep, but short naps can be better than no naps," she said. "It's important to look at the length of rest after 16 hours and see what is optimal."

Lack of compliance with the current duty-hour limits also remains an issue, the report said. In the 2006-07 academic year, the report noted that about 9 percent of ACGME-reviewed residency programs received one or more citations for a violation of any duty hour regulation. To mitigate violations, the report suggests that that ACGME make more frequent and surprise inspection visits to residency programs.

"This would be a major change," said ACGME CEO Thomas Nasca, M.D. "We would become a regulatory body rather than an education accreditation body. Unannounced site visits would change the nature of our relationship to teaching hospitals."

The report estimates that its recommendations would come with an annual $1.7 billion price tag. The AAMC Group on Resident Affairs (GRA) believes that the actual costs may exceed this figure, according to GRA Executive Secretary Sunny Yoder.

"People need to look at this as an investment in patient safety," Johns said. There might be some future cost savings if the amount of medical errors can be reduced, he said. The report encourages federal, state, and local governments, as well as private insurers, to financially support the suggestions.

The report's suggestions and their associated costs will certainly foster more conversations at the ACGME, Nasca said. The council, he said, will "analyze each and every recommendation" in upcoming meetings, although he is hesitant to predict what report suggestions will be implemented.

Even before any ACGME changes are announced, teaching hospitals can use the report as a guidepost when evaluating their own systems, Yoder said.

"The GRA wants to encourage our members to adopt those changes that can be readily made—such as providing more time off between shifts," Yoder said. "We also believe we can help develop means of measuring supervision, improving handovers, and managing residents' workloads."

Medical centers have already been stepping up to meet implementation challenges in inventive ways, said Debra Weinstein, M.D., vice president for graduate medical education at Partners HealthCare in Boston. She notes that her institution offers taxi vouchers to residents after long shifts, something the report suggested.

More innovative approaches are necessary, said Justin Klamerus, M.D., a medical oncology fellow at Sidney Kimmel Comprehensive Cancer Center.

"With the report suggesting additional limits on residents' training schedules, steps must be made so that young doctors can increasingly be devoted to direct patient care," Klamerus said. "Educators must also tap into technology to deliver didactics creatively."

—By Elissa Fuchs