Home Government Affairs Newsroom Meetings Publications	Shopping Cart Site Map

November 2001 Reporter

VA Closure Raises Concern

Putting a Human Face on Stem Cell Research

Politician Physicians Combine Medicine & Public Service

New GME Policy Aims to Ensure Quality Education, Patient Care

A Word from the President

Reporter Archive

AAMC Newsroom

Managing Editor
Scott Harris
sharris@aamc.org

Staff Writer
Elissa Fuchs
efuchs@aamc.org

New AAMC GME Policy Statement Aims to Ensure Quality Education, Patient Care

By Martha Frase-Blunt,
Special to the AAMC Reporter

Conducting high-quality graduate medical education, always challenging, has been exacerbated in recent years by changes in the health care system and shifting patient demographics. Shortened hospital stays, a growing emphasis on ambulatory care, reductions in support staff, and the increased acuity of the average hospitalized patient have placed increased demands on all health care providers, including residents.

"We face a real challenge in medical schools and teaching hospitals as we try to balance the need to maintain a rich educational experience for residents with the equally important need to ensure patient safety and quality of care," says Darrell G. Kirch, M.D., senior vice president for health affairs and dean of the Pennsylvania State University College of Medicine.

"We will not be able to achieve that balance through excessively rigid rules or punching a time clock. It will take ongoing, thoughtful dialogue between residents, faculty, and hospital leadership," says Dr. Kirch, who is a member of the AAMC's Council of Deans Administrative Board and co-chair of the association's Working Group on Institutional Accountability for Graduate Medical Education.

To address the need to provide a more effective learning environment for residents, the AAMC Executive Council recently approved a document that takes a comprehensive look at the status of GME and articulates revised policies on institutional oversight and program support, the educational program, supervision of residents in patient care, and resident duty hours.

"In light of continuing concern about the lengthy duty hours of residents in many training programs across the country, the AAMC initiated a thorough review of its policies regarding the conduct of graduate medical education by member institutions," AAMC President Jordan J. Cohen, M.D., explains.

"The revised policies adopted by the Executive Council reaffirm the association's long-standing view that a reasonable upper limit should be placed on the scheduled duty hours of residents. More important, however, they place the issue of duty hours in the broader context of institutional responsibility for maintaining a learning environment for residents that optimizes the quality of education and the quality of patient care services."

Not Just a Question of Hours Worked

Concerns about resident work hours - a longtime hot-button issue - have assumed a higher profile in recent months since becoming an advocacy focal point for the American Medical Student Association (AMSA). Last spring, AMSA, along with the watchdog organization Public Citizen and the residents' union, the Committee of Interns and Residents, filed a petition with the Occupational Safety and Health Administration (OSHA) requesting the agency to limit resident work hours to 80 hours per week and shifts to 24 hours. In addition, AMSA is leading a national effort to make these and other limits a condition of hospitals' participation in Medicare.

The position of Public Citizen, AMSA, and their supporters on the OSHA petition seems to be that setting up federal regulations by which every hospital must abide is the best way to help overburdened residents and their patients. "Our government rightly recognizes the importance of capping work hours for those who could kill people if they get too tired, such as truckers and pilots," said Sidney Wolfe, M.D., director of Public Citizen's Health Research Group, in a statement. "The government's obligation should be no less for doctors-in-training, who usually work even longer hours."

While the AAMC shares the concerns of these organizations, it advocates a different solution - one that calls for reform in the context of the educational environment rather than government regulation. It also believes that AMSA's focus on duty hours to the exclusion of other elements of GME, including resident supervision and education, is too limited.

According to the AAMC policy statement, "Focusing on excessive duty hours is to focus on the symptoms, not the root cause of the problems affecting GME." That's the linchpin of the argument, says Dr. Kirch. "The most important aspect of the guidelines is that they go far beyond any single issue of working conditions or resident scheduling. They look at the whole context of resident education and highlight the importance of that education being patient-centered, with a constant eye for improving quality of care."

Theresa A. Bischoff, president of New York University Hospitals and Dr. Kirch's co-chair on the AAMC's GME working group, agrees. "We take seriously our responsibility for our three-part mission of education, research, and patient care. Only by looking at the issue of duty hours in the context of the quality of both education and patient care can we truly achieve our mission. It's not just a question of hours worked," says Bischoff, who also serves as chair of the AAMC's Council of Teaching Hospitals and Health Systems.

And treating medical residents as salaried employees disregards the many subtleties and gradations of the educational experience, believes Lazar J. Greenfield, M.D., chair of surgery at the University of Michigan Medical School and head of the ACGME's Residency Review Committee for Surgery. He notes that the Residency Review Committee he chairs "is very interested in identifying all the factors in the working environment that contribute positively and negatively to resident performance. Our approach is that, assisted by qualified personnel, residents can work reasonable hours, care for patients, learn their craft, and become skilled practitioners."

Dr. Kirch agrees that the demands of both education and patient care are highly specialty- and context-specific; blanket rules cannot substitute for good judgment. "As we work together with our student colleagues on this, I would hope that they see these are complex issues that can't simply be solved by government regulation. An important part of their professional education is learning how we can all work together on issues like this without resorting to adversarial approaches."

Members of the AAMC's Organization of Resident Representatives (ORR) welcome the new policy statement, according to Jessica G. Roberts, M.D., a child psychiatry resident at the Tulane University School of Medicine and ORR chair. "I am really pleased with the AAMC's strong emphasis on insti-tutional oversight and program support," she says. "While people have always been concerned about residents' workloads, there's often no one with the authority to bring a program into line." Residents will also embrace suggestions for more responsible institutional supervision, she believes, because they will "ensure residents are getting the appropriately graduated and supervised experiences they need to become excellent physicians."

Dr. Roberts also points to the document's focus on the hospital as an educational setting, not a work environment. "Hours are a problem, fatigue is a problem, but forcing limits on duty hours will diminish our instruction and prevent many people from getting a good residency education," she says. "Sure I want to be well rested when I graduate, but I want even more to be well trained." She much prefers the AAMC's proposals for work-hour limits that take into consideration the need to learn and to provide patient care continuity. "The AAMC's guidelines should stimulate programs to think of ways to use their residents' time more efficiently."

Time for 21st-Century GME

According to Michael Whitcomb, M.D., AAMC senior vice president for medical education, the policy statement addresses two specific audiences: "For our members, we hope this statement will provide clear steps for constructing GME policies and procedures. For those outside our membership, we hope to influence their thinking and shape any GME policies they might develop. Our community needs to take hold of this problem in a more aggressive fashion because there are abuses."

The AAMC document acknowledges the critical role of the ACGME as an accrediting body: enabling the profession to reach consensus on standards for residency training, to monitor compliance with those standards, and to sanction deviation from those standards when necessary. But, it notes, "no matter how effective the ACGME is in fulfilling its role, the success of the GME enterprise depends on the commitment of the individuals and institutions overseeing GME programs to ensure that their programs are of high quality."

Dr. Roberts hopes that residency programs will step up to the plate. "The guidelines are an incentive and a pathway. I hope institutions will embrace them because if not, the outside pressure for petitions and legislation could result in federal statutes. Programs need to make the choice: to make education the primary goal of residency or be willing to allow regulation by outside groups. There has to be a change in the culture of graduate medical education."

Dr. Kirch agrees, adding, "We will never finish the task of improving GME, but I have no question that the educational experience is better today than it has ever been. And because of the energy we are all turning toward these issues now, it will be even better in the future."

Highlights: The AAMC Policy Statement on Graduate Medical Education

I. Institutional Oversight and Program Support

Institutional sponsors of GME should exercise strong, centralized oversight for all of their GME programs.
Institutional sponsors should authorize a single individual at a sufficiently high level in the organization to take overall responsibility for the quality of all GME programs.
Institutional sponsors and individual residency programs should have written policies and established procedures specifying the level of supervision attending physicians must exercise over residents at various training stages and sites.

II. The Educational Program

Residents must have opportunities to participate, under supervision, in patient care activities of sufficient variety and frequency.
Residents must have opportunities to exercise, under supervision, graded, progressive responsibility for the care of patients.
Residents must have opportunities to participate in required conferences, seminars, and other non-patient-care learning experiences, as well as pursue independent, self-directed learning.

III. Supervision of Residents in Patient Care

The faculty physician of record is responsible for the quality of all clinical care services provided to his or her patients.
All clinical services provided by residents must be supervised appropriately.
Individual residency programs should have written guidelines governing supervision of residents, varying according to specialty, intensity of patient care responsibilities, level of experience, and educational requirements.
Program faculty are responsible for determining when a resident is unable to function at the level required to provide safe, high-quality care to assigned patients, and must have the authority to adjust assigned duty hours as necessary.

IV. Resident Duty Hours

Institutional sponsors and individual programs should have written guidelines governing resident duty hours, varying according to specialty, intensity of patient care responsibilities, level of experience, and educational requirements.
In no case should residents be scheduled to be on duty more than 80 hours in any week. On typical clinical rotations, residents should not be scheduled to be on duty for more than 24 hours consecutively; continuous duty in high-intensity settings should, in general, be scheduled for no more than 12 hours. These guidelines must be applied with sufficient flexibility to ensure that thorough exchange of information and proper transfer of patient care responsibilities occur whenever residents who are going off duty sign over the care of patients to other residents or to teaching physicians.
Duty-free intervals between periods on call should be at least eight hours long.
Residents should not be required to have overnight, on-call duty more than one night in three, as averaged over four weeks.