Adapting to the New Duty Hours Requirements
GME Directors Meet to Compare Notes

By Suria Santana

Before the Accreditation Council for Graduate Medical Education's (ACGME) resident duty hour requirements went into effect on July 1, institutions around the country had to implement a number of changes in their clinical and educational processes to limit the total hours residents spent engaged in such activities. At an AAMC conference on the resident duty hours issue held in Chicago at the end of September, participants heard about some of the changes institutions have had to make to come into compliance with the ACGME limits. Conference participants shared their experience in monitoring resident hours, implementing program changes, and assessing the possible outcomes of these operational modifications.

Monitoring resident duty hours

During the AAMC conference, William Friedman, M.D., department of neurosurgery chairman at the University of Florida School of Medicine, described his institution's new mandatory weekly schedule for residents.

Programs' approaches to tracking duty hours have varied according to their individual culture and perceived need. Some residency directors have chosen to keep the monitoring process uncomplicated, simply requiring residents to sign prospective attestation statements in which they pledge to limit their duty hours to the specified 80- hour-a-week maximum. At William Beaumont Hospital's (WBH) obstetrics and gynecology program, residents are required to sign "level-specific attestation statements." Chair and Program Director John Musich, M.D., M.B.A., explained during the AAMC conference that the main factor influencing his decision to make the hours reporting requirements this simple was to keep "the paperwork level low."

First-year residents at WBH sign a contract in which they pledge to abide by the new ACGME requirements. Part of the first-year agreement includes a commitment to serve a monthly average of five weeknight and two weekend call assignments, and to stick to a daytime duty hour assignment schedule starting at 6:00 a.m. and ending at 5:30 p.m., Monday through Friday. First-year residents also commit to reviewing all other ACGME duty requirements pertinent to the OB-GYN program. Second-year residents sign an attestation statement committing to six months of combined night float and regular program daytime duty, as well as six months of regular program daytime duty with weekend call.

All attestation statements instruct residents to commit to at least 10 duty-free hours between all daily duty periods; one full day in seven free of duty; and a call frequency of less than one in three days or nights during non-float, regular program months. Consistent with the ACGME requirements, all of these hours are averaged over four weeks.

Other programs have developed more strict verification processes with continuous data collection of resident duty hours. At Southern Illinois University School of Medicine's (SIUSOM) general surgery program, residents are required to complete monthly time sheets that include information on their regular daytime working hours, in-hospital on-call time, and in-hospital time while on home call. These time sheets are then used for paycheck purposes, explained John Fortune, M.D., the medical school's general surgery program director, adding that if there is "no time sheet, there is also no paycheck."

The residency's program coordinator at SIUSOM checks each resident's reported work hours against leave, vacation, and call schedules, and develops a monthly hours report, according to Dr. Fortune. These monthly reports form the basis of hours trending reports, which are later developed by the residency program director.

Other institutions, such as New York Presbyterian Hospital, have developed Web duty-hours databases with mandatory daily online reporting. The University of Oklahoma Health Sciences Center is using a Web-based system that automatically calculates, based on resident data input, the average hours per week, duty period time off between duty periods, and the number of full days off for every resident over four weeks. The program has a feature that allows residency officials to locate any unreported information and automatically e-mail residents to inform them that data is missing.

Stumbling blocks

Despite such verification mechanisms, some obstacles to tracking and controlling total resident duty hours still remain, according to residency officials. A few programs have had problems with residents who, despite having worked the maximum 30 hours allowed in a duty period, still want to stay in the hospital to observe a procedure or participate in a patient care activity. "Many residents are not happy about having to leave early," said Dr. Musich. A number of program officials have reported on their residents' unwillingness to cooperate with the new standards, a behavior that could, they argue, put entire residency programs in jeopardy.

Institutions requiring residents to voluntarily document their duty hours with time cards or other similar processes have had cases in which residents submitted false time information. The problem is especially acute in surgical specialties, in which the 120-hour workweek culture is still prevalent, and many residents feel that their educational experience is significantly compromised by reduced hours.

Prior to the new regulations, the University of Florida Department of Neurosurgery had only two residents who worked more than 100 hours per week, a full day after call, and commonly had less than 10 hours off between shifts. Since July 1, a system has been designed that, in the words of Department of Neurosurgery Chairman William Friedman, M.D., enables "the slowest resident to remain consistently compliant" with the duty hour limits. Residents have a mandatory weekly schedule that includes one call day per week (a 30-hour shift), three workdays starting at 5:30 a.m. and ending at 7:30 pm (42 hours), and one short weekend duty day of only 6 hours, all of which adds up to a total of 72 hours.

But even if some institutions are able to implement mandatory weekly schedules with controlled duty hours, an activity that could potentially interfere with the spirit of the regulations is moonlighting. Although the ACGME has determined that internal moonlighting should count toward the duty hour limit, external moonlighting does not, and in the opinion of some conference participants this can be just as detrimental as a long duty hour week. If the purpose is to prevent fatigue and overwork among residents, the fact that they are still allowed to spend their free time working outside of their residency programs goes against the intent of the regulations, since these extracurricular activities could take time away from their sleep and rest.

However, prohibiting residents from engaging in certain activities in their personal time in order to keep them from getting fatigued infringes on their privacy rights, some attendees at the AAMC conference pointed out.

Another loophole in the guidelines that could potentially hamper the goal of reduced duty hours involves pager calls that residents have to take from their homes. Because the regulations count home pager duty as a period of rest and residents could potentially receive several pages in one night, they may not be able to rest or sleep at all during these off-site periods.

Institutional adjustments

Many institutions have attempted to reduce the need for resident pages and clerical work by hiring more registered nurses (especially nurse practitioners) and physician assistants. Hospitals that have not been provided with additional funding to hire new personnel have had to adapt to the new requirements by shifting some of the work to junior faculty.

In addition, as pointed out by John Coombs, M.D., associate dean for regional affairs, rural health and graduate medical education at the University of Washington School of Medicine, the new duty hours requirements have created pressures that in some cases have "reduced the flexibility of programs in terms of sick and personal leave." Some programs have been able to just meet the new hour requirements by cutting into time allotted for residents' leave.

Although program directors at the conference expressed their frustrations with overly committed residents who just "did not want to leave" the hospital when it was time to go, another common concern was the opposite effect - the fear that the new educational and operational processes imposed by the hour restrictions may result in a culture change, a shift to a "clock-worker mentality." A few program officials attending the conference said that they have received leave requests from residents for reasons that would not even have been considered by the last generation of residents.

Some argued that what could turn out to be a new - and in their view, more balanced - approach to work hours by this new generation of physicians is actually a very positive development. As Dr. Friedman pointed out during the conference, there are very negative aspects to the "professionalism of the 120-hour workweek." Surgeons of past generations have been so overworked that many ended up as seeing patients as the "enemy," the obstacle to the next hour of rest. Surviving a surgery residency was rough, the equivalent of a "military or fraternity initiation," said Dr. Friedman, and as a result many surgeons developed a rather cynical attitude.

ACGME's director of field activities, Ingrid Philibert, agreed that a shift in physicians' work mentality is overdue. "We need to decouple notions of professionalism from the number of hours worked," said Philibert, adding that sticking to the old long duty hours mentality might leave residents with a sense of "missing something" crucial in their education.

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