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Limits on Duty Hours Main Topic at GRA Meeting

With the Accreditation for Graduate Medical Education (ACGME) resident duty hour requirements set to take effect July 1, the issue was the primary topic of discussion at the spring conference of the AAMC's Group on Resident Affairs (GRA), held in Philadelphia in late April.

The ACGME requirements mandate that residents' work schedules be limited to 80 hours per week, averaged over a four-week period. The standards - which were brought about primarily by public concern over resident fatigue - allow for exceptions in cases where institutions show "sound educational rationales" for exceeding the limit by up to 10 percent. They also set a minimum 10-hour break between duty periods and require teaching hospitals to give residents at least one full day off from patient care duties every week.

GRA members expressed some concerns around implementation of the new standards. One is the requirement that faculty and residents be educated to "recognize the signs of fatigue and adopt and apply policies to prevent and counteract [its] potential negative effects" on tired residents. GRA attendees noted there are no specific guidelines in place on how to properly identify signs of fatigue and said it is not clear exactly how institutions should go about educating faculty and residents to recognize it.

GRA members also expressed concern about meeting the new standard without having access to additional resources. In attempting to reduce hours, some of the work residents now perform that is not essential to their educational experience will have to be transferred to other hospital staff, in some cases requiring the employment of more healthcare workers and support personnel, they said.

Similarly, limiting resident duty hours might call for substantial investment in information technology to slash time spent by residents and other hospital staff in administrative activities. Considering teaching hospitals' strained budgets, such investments might not be financially viable.

'Radical redesign'

One GRA member said that in order to meet the new requirements, teaching hospitals will have to implement a "radical redesign" of how health care is provided. "We will need to invent new solutions for doing the same things, in less time … and void activities that are non-educational," he said.

Other GRA members said that residents' education must be "balanced with concerns for patient safety." More studies need to be conducted to find out how inevitable disruptions in the continuity of care might affect patient safety and satisfaction, and the quality of care, they said.

In a plenary session reviewing some of the critical aspects of the revised institutional requirements, Ronald Berggren, MD, chair of the ACGME's Institutional Review Committee, noted the importance of a team approach when implementing operational changes in response to the new regulations.

"This has to be a joint endeavor between [all the parties] involved," Dr. Berggren said. "There has to be a trust and willingness to listen to residents in particular and get the information [that is needed]."

Giving advice to institutions that house a large number of residency programs and that, consequently, face a large task in monitoring residency duty hours, he suggested that they "round up the usual suspects … You know where duty hours are most likely to be violated. High-intensity specialties. High-intensity services. Go to the places where [duty hours] are most likely to be violated and see that you can work out an arrangement to make things better," he said.

Institutional experience

Some institutions that have already successfully implemented restricted duty hour standards shared some of their experiences in monitoring them, including representatives from New York state healthcare institutions. New York law has limited residents to 80 hours per week since 1989.

Diane Hartmann, MD, associate dean for graduate medical education and an associate professor of obstetrics and gynecology at the University of Rochester School of Medicine and Dentistry, talked about the educational, monitoring and reporting processes of her institution's duty hour compliance plan.

Some of the policies Rochester has adopted include simple yet effective things such as informing new residents about the regulations during orientation, making program directors responsible for distributing program-specific requirements to trainees and faculty, and conducting mandatory surveys to find out how many hours residents work.

At the David Geffen School of Medicine at UCLA, graduate medical education [GME] officials hired internal auditors to review residency program records to ensure that their compliance plans meet the standard. Kimberly Crooks, Ph.D., director of GME at UCLA-Geffen, said in a session that the institution also had established an anonymous telephone hotline to report duty hour violations.

Some of the techniques shared by other institutions on limiting residents' work included placing residents on teams that cover more than one service, eliminating residents' presence in clerical assignments, and, in some cases, passing on some of their duties to physician assistants and nurse practitioners.

- Suria Santana

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