New ACGME letter on Revised Standards

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
exPCM

exPCM

Membership Revoked
Removed
10+ Year Member
15+ Year Member
Joined
Apr 12, 2006
Messages
919
Reaction score
8
Members do not see this ad.
May 4, 2010
Dear Program Directors, Members of the Faculty, Designated Institutional Officials, Residents and Fellows of the United States,
It has been about five months since I last shared an update on the progress of the task force charged with drafting standards relating to professional responsibility, transitions in care, supervision and resident duty hours for the profession. I am pleased to relate that the work of the group is nearly complete, and that their recommendations will soon begin to traverse the path that all program requirement revisions must follow on their way to approval by the ACGME Board of Directors .
The ACGME Task Force: A Uniquely Qualified Team
The task force was formed nearly 12 months, with the goal of fulfilling the ACGME's promise to the community to revisit the 2003 Resident Duty Hour Standards after five years. The task force is composed of sixteen members, twelve of whom have vast experience in the breadth of graduate medical education. Six representatives are members of the surgical community, six are from the medical community, and three are from the hospital based specialties community. The group includes three residents nearing completion of their training, and a public representative with extensive experience in evaluation of health care related issues.
Collectively, the 12 members of the task force who are clinician educators have over 250 years of formal experience in the organization and provision of medical education in the context of patient care. Every position in the organization and delivery of education in the medical, surgical, and hospital based specialties has been held by one or more members of the task force, from generalist through subspecialist faculty member, program director, designated institutional official, associate deans for education, research, patient care, dean of the medical school, senior vice president for academic affairs of the university, residency review committee member, chairs of residency review committees, and member and chair of the board of the ACGME.
The members of the task force have been leaders in professional organizations outside the ACGME, including chairs of their respective specialty boards, and officers of their respective specialty societies, colleges, or academies. Collectively, they have authored more than 1,000 peer reviewed articles, books, chapters, and other publications, and
have delivered more than 2,000 national or international presentations. They currently serve in institutions located in all geographic sections of the country, and represent the wide array of academic institutions involved in graduate medical education.
This task force is uniquely qualified, as no other, to address the issues and challenges placed before it.
The ACGME Task Force Incorporated An Extensive Fact Gathering and Review Process
The members of the task force chose to listen to the profession and the public before placing pen to paper.
They received testimony from nearly 100 individuals, representing the breadth of medicine and medical education, including presentations from members of the profession in the United Kingdom and Canada. They received the written formal positions of more than 100 medical organizations, and heard directly from 72 of those organizations during the National Congress on Duty Hours and the Learning Environment held in Chicago in June, 2009.
They read, and then received formal presentations and had extensive discussions with members of the Institute of Medicine (IOM) Committee that drafted the important report entitled, "Resident Duty Hours: Enhancing Sleep, Supervision, and Safety." The task force heard from four members of the IOM Committee, and invited three members back for further in depth discussion. The members of the task force are, and the profession should be indebted to the members of the IOM Committee for their contributions to this national dialogue, and the framing of key issues beyond duty hour standards related to patient safety for the educational community to discuss and debate.
The task force received presentations and had discussions with a number of experts in sleep physiology and sleep medicine with varying perspectives on the issues at hand.
They heard presentations by experts in: fatigue mitigation, patient safety, quality improvement, hand-overs of care, professionalism, the legal dimensions of duty hour standards, the impact of the New York State duty hour standards, the unique challenges and trade-offs faced by America's Safety Net Hospitals, and the financial impact of the current and the IOM suggested modifications of current ACGME standards. These presentations informed the deliberations in areas beyond resident duty hours.
The task force commissioned three external reviews of the literature on various dimensions of the questions at hand, received a formal review of the legal dimensions of regulation of duty hours, and a presentation on lessons learned from implementation of the current duty hour standards.
The committee took seriously the "common sense" recommendations of the profession, that "one size does not fit all," when it comes to duty hour standards, and that ethical breaches should not be fostered in order to meet the needs of the individual patient.
The Task Force Maintained Equal Focus: Providing an Excellent Educational Environment and Quality, Safe Patient Care
Perhaps the most important series of presentations were those of Patient Representatives to the task force. These conversations, and their powerful messages, focused the vision of the task force clearly on what were to become our overriding principles. These overriding principles are:
• Patients must be safe, and receive excellent care, in the teaching setting today.
• Patients must be safe, and receive excellent care, in the setting of the unsupervised care of patients in the future career of today's residents. This requires that we must deliver outstanding education today.
• Residents must be educated in a humanistic educational environment that protects their safety, and nurtures professionalism and the effacement of self interest that is the core of the practice of medicine and the profession in the Unites States.
It should be emphasized that all three of these principles are equal, and must be fulfilled. They are not mutually exclusive goods; they are absolute "goods" and must be achieved. Furthermore, those principles and their articulation in standards go far beyond the issues of resident duty hours. Certain of their dimensions, however, are captured in the output of this task force.
The draft standards written by the task force will address the above principles with expectations regarding: resident supervision, resident and faculty professionalism and fitness for duty, patient safety and quality improvement expectations, handover processes and inter-professional communications, as well as duty hours.
Next Steps
The work of the task force is nearly complete. Over the next six weeks, standards will be refined and prepared for review by the Council of Review Committees, which consists of the chairs of each of the twenty eight review committees of the ACGME. The responsibility of this Committee is to discuss, and if endorsed, offer the draft for public comment. The standards will then be posted on the ACGME Website for 45 days of public comment. Based on that feedback derived from those comments, the standards may be modified.
They will then be presented to the Program Requirements Committee of the Board, and if approved, presented to the Board of Directors of the ACGME for approval.
The revised standards, combined with the dual oversight of the review committees and the ACGME Board approved Annual Sponsor Site Visit Program, will assure the public and the profession of the homogeneous implementation of these commitments. In this fashion we will fulfill ACGME's promise to the community to revisit its standards, and move closer to a time when our three principles are more than aspirational statements in every program.
The task force wishes to publically thank each person and organization that provided input into this extensive review of ACGME standards. The ACGME thanks the members of the task force for the generous gift of time, expertise, and wisdom in their deliberations on behalf of the profession and the public.
The task force and the ACGME invite all to review and comment (both positive and constructive criticism) on the requirements when they are posted in late June.
Sincerely,
Thomas J. Nasca, M.D., MACP
Chief Executive Officer
Accreditation Council for Graduate Medical Education

http://www.acgme.org/acWebsite/home/NascaLetterCommunity5_4_10.pdf

Comment: Will be interesting to see what they have come up with. They promised to revisit the 2003 duty hours standards after 5 years (It is now 7 years later). Coincidentally this was posted on Reuters yesterday:

Memo to boss: 11-hour days are bad for the heart
Ben Hirschler
LONDON
Tue May 11, 2010 3:15pm EDT

LONDON (Reuters) - People working 10 or 11 hours a day are more likely to suffer serious heart problems, including heart attacks, than those clocking off after seven hours, researchers said on Tuesday.

U.S. | Health | Lifestyle

The finding, from an 11-year study of 6,000 British civil servants, does not provide definitive proof that long hours cause coronary heart disease but it does show a clear link, which experts said may be due to stress.

In all, there were 369 cases of death due to heart disease, non-fatal heart attacks and angina among the London-based study group -- and the risk of having an adverse event was 60 percent higher for those who worked three to four hours overtime.

Working an extra one to two hours beyond a normal seven-hour day was not associated with increased risk.

"It seems there might a threshold, so it is not so bad if you work another hour or so more than usual," said Dr Marianna Virtanen, an epidemiologist at the Finnish Institute of Occupational Health and University College London.

The higher incidence of heart problems among those working overtime was independent of a range of other risk factors including smoking, being overweight or having high cholesterol.

But Virtanen said it was possible the lifestyle of people working long hours deteriorated over time, for example as a result of poor diet or increased alcohol consumption.

More fundamentally, long hours may be associated with work-related stress, which interferes with metabolic processes, as well as "sickness presenteeism," whereby employees continue working when they are ill.

Virtanen and colleagues published their findings in the European Heart Journal.

Commenting on the study, Gordon McInnes, professor of clinical pharmacology at the University of Glasgow's Western Infirmary, said the findings could have widespread implications for doctors assessing patients' heart risks.

"If the effect is truly causal, the importance is much greater than commonly recognized. Overtime-induced work stress might contribute to a substantial proportion of cardiovascular disease," he said.
http://www.reuters.com/article/idUSTRE64A2SR20100511
 
Last edited:
it looks like to me just by reading in between the lines that the recommended changes will be
-eliminating 30 hr shift but probably not coming all the way down to 16 hr shift limit that the IOM recommended
-will definitely not raise 80 hr/week limit but will probably not lower it much if at all either. i would be shocked to see 60 hr work week recommendation
-much stricter enforcement of duty hours requirements
-and though he says "not one size fits all," i dont believe they will set up different rules regarding different specialties. makes things too complicated.
 
Johnjonny21 said:
it looks like to me just by reading in between the lines that the recommended changes will be
-eliminating 30 hr shift but probably not coming all the way down to 16 hr shift limit that the IOM recommended
-will definitely not raise 80 hr/week limit but will probably not lower it much if at all either. i would be shocked to see 60 hr work week recommendation
-much stricter enforcement of duty hours requirements
-and though he says "not one size fits all," i dont believe they will set up different rules regarding different specialties. makes things too complicated.
Click to expand...

I think you may be right with your predictions. It will be interesting to see next month. Since they have worked on this for so long I do not think they will change anything based on the 45 days of public comments (although I may be proven wrong).
 
Johnjonny21 said:
it looks like to me just by reading in between the lines that the recommended changes will be
-eliminating 30 hr shift but probably not coming all the way down to 16 hr shift limit that the IOM recommended
-will definitely not raise 80 hr/week limit but will probably not lower it much if at all either. i would be shocked to see 60 hr work week recommendation
-much stricter enforcement of duty hours requirements
-and though he says "not one size fits all," i dont believe they will set up different rules regarding different specialties. makes things too complicated.
Click to expand...

exPCM said:
I think you may be right with your predictions. It will be interesting to see next month. Since they have worked on this for so long I do not think they will change anything based on the 45 days of public comments (although I may be proven wrong).
Click to expand...

By "not one size fits all" I think they'll limit PGY-1's to 16 hour shifts, but allow PGY-2+ to do overnight call.

And I agree with exPCM. The 45 day public comment period is required by ACGME bylaws, but nothing will change regardless of comments.
 
aProgDirector said:
By "not one size fits all" I think they'll limit PGY-1's to 16 hour shifts, but allow PGY-2+ to do overnight call.

And I agree with exPCM. The 45 day public comment period is required by ACGME bylaws, but nothing will change regardless of comments.
Click to expand...

aprogdirector,
If you are correct then I can see all the transitional and prelim medicine residents who are on their way to ophthalmology, radiology, anesthesiology, dermatology, etc. having a major celebration since they will be off the hook for overnight call during the PGY-1 year.
 
aProgDirector said:
By "not one size fits all" I think they'll limit PGY-1's to 16 hour shifts, but allow PGY-2+ to do overnight call.

And I agree with exPCM. The 45 day public comment period is required by ACGME bylaws, but nothing will change regardless of comments.
Click to expand...

why would they change shift limit between PGY-1 vs. PGY-2+? If the main reason for shift limit is for "patient safety" and that patient shouldnt be treated by exhausted resident, then the same rules should apply to all years.
 
Johnjonny21 said:
why would they change shift limit between PGY-1 vs. PGY-2+? If the main reason for shift limit is for "patient safety" and that patient shouldnt be treated by exhausted resident, then the same rules should apply to all years.
Click to expand...
For the record, let me repeat: I have nothing to do with this possible decision, was not on the committee that is making it, and have no real knowledge of what is to come. Everything I am saying is educated guesswork.

I think the rules will only apply to PGY-1, with the following (perhaps faulty) logic:

1. PGY-1's have the least knowledge. Hence, they are most likely to make a mistake, and need the most protection.
2. In general, as you ascend the PGY ladder, you tend to get called less while on call.
3. The surgical fields probably choked on the thought of no overnight call. They likely want their surgical senior residents (PGY-4+) to take 24 hour shifts -- again, they are not getting called with every little thing, mostly getting called to evaluate acutely ill patients for possible surgical intervention. Since surgical staff take 24 hour call in most places, it makes some sense to allow surgical chief residents to do so also.

So, I expect this is more of a compromise than anything else. Getting no overnight call across the board was probably politically impossible.

Note, again, I do not really know what is coming nor how that decision was reached. My thoughts / guesses are all constructed by listening to what "those in the know" said at the APDIM meeting, and reading between the lines. We'll all know in the next month or so.
 
Wouldn't a 16-hour limit violate the current 10-hour-off rule? If you're expected in at 7 am, but have a 16-hour shift on call, you finish at 11 pm. You wouldn't be "allowed" back until 9 am the next day. Even a sleazy program would have trouble hiding that violation, which would be committed by multiple residents every day of the week.

Here's an idea. It's not even new. How about keeping overnight call if necessary but not having the on-call resident/intern come in until later in the day, say 3 pm? A number of anesthesia programs do that, completely voluntarily. They manage to keep the ORs adequately staffed during the daytime. (Small caveat: only the seniors generally get to do this at these programs; the CA-1s i.e. PGY-2s work the full day before taking overnight call.)
 
So are any of these changes likely going to affect THIS incoming group of interns starting next month? I just want to understand that this means no overnight call for interns would become required policy?
 
Richard Cypher said:
So are any of these changes likely going to affect THIS incoming group of interns starting next month? I just want to understand that this means no overnight call for interns would become required policy?
Click to expand...

I'm not the expert here. Be forewarned.

But I would answer a resounding NO, with enough certainty to put money down on it. It would probably be unreasonable to expect programs to implement such large changes with less than a month's notice. I wasn't even close to being in medicine when the 80-hour work week was adopted a number of years ago, but from what I've heard I think the policy was adopted in 2002 but didn't go into effect until July 2003.

All that being said I'm definitely now really curious about what's actually going to shake out of this...something revolutionary along the lines of the 80-hour rule, or just a bunch of nothing that keeps the status quo in place?
 
the fat man said:
Wouldn't a 16-hour limit violate the current 10-hour-off rule? If you're expected in at 7 am, but have a 16-hour shift on call, you finish at 11 pm. You wouldn't be "allowed" back until 9 am the next day. Even a sleazy program would have trouble hiding that violation, which would be committed by multiple residents every day of the week.

Here's an idea. It's not even new. How about keeping overnight call if necessary but not having the on-call resident/intern come in until later in the day, say 3 pm? A number of anesthesia programs do that, completely voluntarily. They manage to keep the ORs adequately staffed during the daytime. (Small caveat: only the seniors generally get to do this at these programs; the CA-1s i.e. PGY-2s work the full day before taking overnight call.)
Click to expand...

They could limit to 16 hours and leave the 10 hour off rule in place. Yes, as you point out, since 16+10=26 which is greater than 24, if you had someone do a 16 hour shift they would need to come in later the next day. or you could have them do a 14 hour shift. Or, it's possible that they will decrease the shift break to 8 hours -- The IM RRC has done this: if you have a service that has no overnight call, you're allowed to have a late day q4 with an 8 hour break rather than 10.

As far as your other idea, bringing people in late, it works great if your in Anesthesia or ED, fields where there is no continuity. In IM, you can't simply start a team at 3PM -- some patients covered by that team will need to be discharged, etc. We tried "staggering" one of the members of our ward team -- we had the resident come in at 1PM on their call days. It was a disaster -- mainly because the resident hated missing morning rounds and knowing what was going on with patients, and making those key decisions.

Richard Cypher said:
So are any of these changes likely going to affect THIS incoming group of interns starting next month? I just want to understand that this means no overnight call for interns would become required policy?
Click to expand...

No, whatever changes are coming will be for July 2011.
 
IMHO, never for most.

I think the theory is that if residencies focus the time available on "quality learning" then residents can learn what they need in order to graduate and be competent. Whether that's acutally accurate is another story.

If Ortho were to decide that 5 years (or whatever their current training time is) was insufficient, they could simply increase to 6 and that would be that.

If IM were to try to increase to 4 years, there would be hell to pay. First, if FM stays at 3 people interested in primary care might simply do FM rather than IM. Second, the subs would go nuts, and would likely demand that residents be allowed to go into a sub after 3 years and only finish a 4th year if staying in general IM -- which of course would push more people into subs, because why not if you have a whole extra year to do anyway?

I expect we'll see more of a push to graduate people based on "competency". Honestly, there are some residents in my program whom after 2 years would probably be fine to graduate and practice. There are some who need 3.5-4 years. We have a system that forces everyone to get exactly 3 years of training. It makes some sense to allow people to graduate at 3 years, and keep some people for an extra 6-12 months if they need it rathe rthan forcing everyone to 4 years...

... except that's doomed to failure. How am I really supposed to tell who need 36 vs 42 vs 48 months of training? Sure, I can tell you whom the strongest and weakest residents in my program are, but I'd need some sort of rock solid, unquestionable, objective measure to determine whether people were ready to graduate at 36 months -- and that doesn't (and never will) exist.
 
Gastrapathy said:
When will they make the residencies longer to correspond to the decrease in hours?
Click to expand...

Maybe aPD can correct my misguided thought process here...

So let's play this out. Unless you cut the number of residents taken at a program per year, you now have 4/3 as many residents as you used to in the case of a 3-year residency. For example you now have 100 residents hanging around to do the work that 75 used to do. Assuming the hospital can't add new beds and they're already at capacity, a resident's average workload is now 3/4 of what it used to be and therefore has 3/4 of the training per year he or she originally was getting. So when all is said and done, a resident has now spent an extra year....which has resulted in exactly the same amount of patient care experience has he/she would have gotten during the old 3-year residency!

Excuse my cynicism here, but just sounds like another sour grapes argument that's more about the resentment that the docs who trained before us had to work more hours than we do today. However in fairness to us newbies, we carry WAY more med school debt and may stand to make considerably less over our careers than those who come from the age of giants. So I wouldn't say we necessarily made out like bandits.
 
the fat man said:
Maybe aPD can correct my misguided thought process here...

So let's play this out. Unless you cut the number of residents taken at a program per year, you now have 4/3 as many residents as you used to in the case of a 3-year residency. For example you now have 100 residents hanging around to do the work that 75 used to do. Assuming the hospital can't add new beds and they're already at capacity, a resident's average workload is now 3/4 of what it used to be and therefore has 3/4 of the training per year he or she originally was getting. So when all is said and done, a resident has now spent an extra year....which has resulted in exactly the same amount of patient care experience has he/she would have gotten during the old 3-year residency!

Excuse my cynicism here, but just sounds like another sour grapes argument that's more about the resentment that the docs who trained before us had to work more hours than we do today. However in fairness to us newbies, we carry WAY more med school debt and may stand to make considerably less over our careers than those who come from the age of giants. So I wouldn't say we necessarily made out like bandits.
Click to expand...


So you cut class size to bring things into equilibrium 😉 This has the added "benefit" of contracting provider supply. Oh wait, we're supposed to be increasing PC production? And cutting class size would make the new work hour restrictions impossible to adhere to? hmm...

I'm just throwing this out there, in a completely uneducated fashion, but isn't the whole purpose of the specialty board to certify a physician's competence in that field? Why not change the minimum standard from board eligibility to board certification? For instance for IM, perhaps someone could become BE after 24-30 months of residency, but BC is required for actual graduation. If you pass your boards at 36 months, you're done. If not, you continue residency and try again in 6 months. This allows for an objective measurement of competence, allows a resident to graduate in 3 years if prepared, and allows a program to retain a trainee if he/she is not prepared. Perhaps this would have an added benefit of 'encouraging' programs with poor first time pass rates to improve their didactics? Any thoughts?
 
the fat man said:
Maybe aPD can correct my misguided thought process here...

So let's play this out. Unless you cut the number of residents taken at a program per year, you now have 4/3 as many residents as you used to in the case of a 3-year residency. For example you now have 100 residents hanging around to do the work that 75 used to do. Assuming the hospital can't add new beds and they're already at capacity, a resident's average workload is now 3/4 of what it used to be and therefore has 3/4 of the training per year he or she originally was getting. So when all is said and done, a resident has now spent an extra year....which has resulted in exactly the same amount of patient care experience has he/she would have gotten during the old 3-year residency!

Excuse my cynicism here, but just sounds like another sour grapes argument that's more about the resentment that the docs who trained before us had to work more hours than we do today. However in fairness to us newbies, we carry WAY more med school debt and may stand to make considerably less over our careers than those who come from the age of giants. So I wouldn't say we necessarily made out like bandits.
Click to expand...

The "error" with this argument is that not all of the work done in the hospital is done by residents. Because of work hour regs, most (if not all) programs have developed some sort of uncovered service. Hence, if we increased residency to 4 years, more of this uncovered work could be switched to residents, and hence residents would get more experience.

Please note that I'm not suggesting this is a good idea, just why your argument is incomplete.

MattD said:
So you cut class size to bring things into equilibrium 😉 This has the added "benefit" of contracting provider supply. Oh wait, we're supposed to be increasing PC production? And cutting class size would make the new work hour restrictions impossible to adhere to? hmm...

I'm just throwing this out there, in a completely uneducated fashion, but isn't the whole purpose of the specialty board to certify a physician's competence in that field? Why not change the minimum standard from board eligibility to board certification? For instance for IM, perhaps someone could become BE after 24-30 months of residency, but BC is required for actual graduation. If you pass your boards at 36 months, you're done. If not, you continue residency and try again in 6 months. This allows for an objective measurement of competence, allows a resident to graduate in 3 years if prepared, and allows a program to retain a trainee if he/she is not prepared. Perhaps this would have an added benefit of 'encouraging' programs with poor first time pass rates to improve their didactics? Any thoughts?
Click to expand...

An interesting idea, although it would create havoc with trying to find a job. I suggest that my residents settle on a position at least 4 months prior to the end of residency -- to deal with licensing etc. Most are looking for jobs for several months prior. I guess you could take the boards, look for jobs, and then if you fail you don't graduate. This also assumes that more training will help someone pass a written exam, which is by no means clear.
 
A 3-year IM residency is recent: prior to 1983 residencies were two years, and prior to 1979, a intern year and you were done. The 3-year concept of learn, do, then teach has been bloated with scut, paperwork, and time wasting - with even less teaching from staff.

What should come from these "rules" modifications are a change curriculum, and a change in mindset that education should be the focus of residency.
 
Moonglow said:
A 3-year IM residency is recent: prior to 1983 residencies were two years, and prior to 1979, a intern year and you were done. The 3-year concept of learn, do, then teach has been bloated with scut, paperwork, and time wasting - with even less teaching from staff.

What should come from these "rules" modifications are a change curriculum, and a change in mindset that education should be the focus of residency.
Click to expand...

Not to mention that hospital stays are increasingly shorter. You can see and work up a lot more total cases now in much less time. Of course with the ridiculous amounts of paperwork now required, our training in the delivery of actual care is hampered. I can probably count the number of times in med school on one hand that an attending gave our team real bedside teaching. On the other hand there were countless times where the teaching consisted of reading and evaluating my H&P's. Which are also now generally invalid for official use, requiring my interns and residents to redo the work I'd already done for them, giving them less time to learn and teach.
 
aProgDirector said:
An interesting idea, although it would create havoc with trying to find a job. I suggest that my residents settle on a position at least 4 months prior to the end of residency -- to deal with licensing etc. Most are looking for jobs for several months prior. I guess you could take the boards, look for jobs, and then if you fail you don't graduate. This also assumes that more training will help someone pass a written exam, which is by no means clear.
Click to expand...


Great point, I hadn't considered the difficulty in finding a job, with employers unsure of your employability until the actual time of graduation. I also agree that more training may not be useful in passing written/oral boards, I was just choosing a standardized metric that could be used objectively in deciding if a resident should be put on the 'extended track', so to speak. I'll leave it to those with experience to determine the appropriate metric 🙂
 
aProgDirector said:
By "not one size fits all" I think they'll limit PGY-1's to 16 hour shifts, but allow PGY-2+ to do overnight call.

And I agree with exPCM. The 45 day public comment period is required by ACGME bylaws, but nothing will change regardless of comments.
Click to expand...

I recently attended a grand rounds by a member of this 15-member ACGME committee. The person was not at liberty to comment on any specific recommendations but strongly hinted at a number of things. The final report will be out in 4 weeks for public feedback and possibly revision, with implementation set for July 2011.

One, the 'not one size fits all' thing will refer to the various specialties not PGY status; ACGME will lay out some core mandatory changes to the CPRs but leave it to the various RRCs to implement some of the softer recs. Two, staff oversight will be better defined; the impression I got was round-the-clock in-house attending coverage may be coming to a theater near you and will be the means for providing resident sleep time or filling the gap to be left by shortened shifts. Three, there will be alignment with a third party (possibly the CIR/SEIU) as a way of truly assessing resident working conditions. Four, some sort of tool or metric will be put in play to evaluate resident alertness.

At no point in the presentation was there mention of altering the 80 hour week or changing residency length. Again, the speaker was unable to comment on exact recommendations but gave some hints. These are the things I took away for what they're worth, but again we'll all see for sure next month. More than anything though, the overriding theme was that pressure was being ramped up politically to do something in regards to the profession policing itself to prevent mistakes OR ELSE having (this) government step in and clusterf*ck it all up for everybody.
 
Tic said:
I recently attended a grand rounds by one member of this 15-person ACGME committee. The person was not at liberty to comment on any specific recommendations but strongly hinted at a number of things. The final report will be out in 4 weeks for public feedback and possibly revision, with implementation set for July 2011.

One, the 'not one size fits all' thing will refer to the various specialties not PGY status; ACGME will lay out some core mandatory changes to the CPRs but leave it to the various RRCs to implement some of the softer recs. Two, staff oversight will be better defined; the impression I got was round-the-clock in-house attending coverage may be coming to a theater near you and will be the means for providing resident sleep time or filling the gap to be left by shortened shifts. Three, there will be alignment with a third party (possibly the CIR/SEIU) as a way of truly assessing resident working conditions. Four, some sort of tool or metric will be put in play to evaluate resident alertness.

At no point in the presentation was there mention of altering the 80 hour week or changing residency length. Again, the speaker was unable to comment on exact recommendations but gave some hints. These are the things I took away for what they're worth, but again we'll all see for sure next month. More than anything though, the overriding theme was that pressure was being ramped up politically to do something in regards to the profession policing itself to prevent mistakes rather than having (this) government step in and clusterf*ck it all up for everybody.
Click to expand...

when has any profession been able to "police itself?" Wall street...erg... that didn't turn out so good. medicine...every surgical residency is consistently going over 80 hrs a week. I am usually a conservative on most issues, but it is time for the government to get involved and enforce fair labor practices.
 
I am concerned that the ACGME uses the terms "excellent" and "outstanding" in its above statement regarding patient care and resident education.

In an academic setting, which ostensibly what residency training is about, the terms excellent and outstanding correspond to magna cum laude and summa cum laude respectively. By definition, these goals can only be achieved, if at all, by a select minority of students. Likewise, only "outstanding" students make AOA. Residents must achieve these requirements to graduate.

The problem is that these high goals cannot be achieved by the majority of residents. Only a minority who finish residency training can truly claim to be excellent or outstanding. It would be delusional for every graduate to think that since he graduated, he must be excellent or outstanding. The correct term should be "reasonable."

These high standards could lead to arbitrariness in the promotions process. The excellent or outstanding standard could be used to eliminate the majority of residents from training; however, its severity is mitigated by selective enforcement and disparate treatment. The standards espoused by the ACGME could be construed too literally by program directors who abuse their discretion; the result being tyranny. The standards could then paradoxically lead to worsened clinical competency. To avoid selective enforcement of the standards, the majority of residents would curry the favor of program leadership. The righteous may end up being persecuted, because they cannot against good conscience curry favor for self-gain. Thus these standards could prevent a true meritocracy from taking root.

Ironically, the excellent or outstanding standard unnecessarily limits competition. We do not all need to be excellent or outstanding physicians to practice medicine effectively with reasonable care.

The law only requires reasonable care in the execution of duties particular to our profession. The states delegate this regulatory authority to our professional governing bodies. If these professional governing bodies interpret a reasonable standard as excellent or outstanding, they may on their own rewrite the law and reach beyond the delegation of their authority.
 
Last edited:
Roofie said:
I am concerned that the ACGME uses the terms "excellent" and "outstanding" in its above statement regarding patient care and resident education.

In an academic setting, which ostensibly what residency training is about, the terms excellent and outstanding correspond to magna cum laude and summa cum laude respectively. By definition, these goals can only be achieved, if at all, by a select minority of students.
Click to expand...

You're assuming a relative definition of excellent and/or outstanding. If Outstanding is defined as the "top 10%", then of course only 10% qualify. If you define Outstanding as some absolute cutoff, then it totally depends on where you define that cutoff as to how many will be "Outstanding".

I think you're over-reading this letter. Nasca is simply warning all involved that big changes are coming, and that there is no point fighting fate.
 
bump! isnt it time for them to publish their recommendations?
 
Johnjonny21 said:
bump! isnt it time for them to publish their recommendations?
Click to expand...

The task force and the ACGME invite all to review and comment (both positive and constructive criticism) on the requirements when they are posted in late June.
Sincerely,
Thomas J. Nasca, M.D., MACP
Chief Executive Officer
Accreditation Council for Graduate Medical Education
Click to expand...

So...no.
 
Just a few links on articles that have recently arisen regarding this topic

http://www.the-hospitalist.org/details/article/712439/New_Resident_Regulations_on_the_Horizon.html

http://www.the-hospitalist.org/details/article/704913/The_Cost_of_Regulation.html - does a good job of pointing out the cost of this, my favorite line " "Any replacement of a resident costs more than a resident, "


http://www.medscape.com/viewarticle/721694 - something for the neurosurgery residents who get beat down every call.....🙂

Couldn't find much on what they plan to do specifically for surgery/sub-specialties ( as the rumor is there is not a one size fits all solution)...rumors are they want to leave the acgme, and some programs are limited to one resident a year with q3-4 call, where it wouldn't really work to give a 5 hour break every call night, just not enough residents for some programs, it would seem...... should be interesting to see.
 
Assuming the above person is correct, does anyone have link to the new rules or any idea what was released? Thanks.
 
[/QUOTE]The surgical fields probably choked on the thought of no overnight call. They likely want their surgical senior residents (PGY-4+) to take 24 hour shifts -- again, they are not getting called with every little thing, mostly getting called to evaluate acutely ill patients for possible surgical intervention. Since surgical staff take 24 hour call in most places, it makes some sense to allow surgical chief residents to do so also.
[/QUOTE]

I disagree, based on the years I spent as a surgery resident. The chiefs didn't like to take overnight call. The things that go to the OR in the middle of the night are cases like appys, SBO and rectal abscesses (aka "butt puss") None of these are chief level cases. For a chief to be on call doing consults and appys, and then have to go home post call and miss out on Whipples and other more complex, elective cases is generally not good for their education. PGY 3 and 4 should be able to do the emergency cases at night.
 
notinkansas said:
I disagree, based on the years I spent as a surgery resident. The chiefs didn't like to take overnight call. The things that go to the OR in the middle of the night are cases like appys, SBO and rectal abscesses (aka "butt puss") None of these are chief level cases. For a chief to be on call doing consults and appys, and then have to go home post call and miss out on Whipples and other more complex, elective cases is generally not good for their education. PGY 3 and 4 should be able to do the emergency cases at night.
Click to expand...

Agreed...while the operative trauma cases would be good experience, the vast majority of late night/overnight cases are not Chief level cases. If your program was serious about work hours, you would get sent home instead of staying doing doing those Chief level cases as noted above.
 
doctorFred said:
they were released today, i believe (june 21st.)

let me add that i don't know what they are, only that the academic officer at my residency mentioned they were released for comment today and will likely be put into place effective july 1st, 2011.
Click to expand...

Bump. Anyone know what's up? I haven't been able to find it online.
 
I received this message by email this morning from the GME office:

At 5PM today the new ACGME duty hours will be posted on the ACGME website. At the same time the weekly eNEJM email will come out with an article about the proposed rules. The community has 45 days to comment after which the taskforce will review comments and make the final proposal to the ACGME board. Implementation is expected 1 July 11.
 
this is pretty exciting. i wonder if this will be as ground-breaking as 2003's changes or just simply an amendment to previous duty hour rules (i.e. simply stronger enforcement but no significant changes)
 
Johnjonny21 said:
this is pretty exciting. i wonder if this will be as ground-breaking as 2003's changes or just simply an amendment to previous duty hour rules (i.e. simply stronger enforcement but no significant changes)
Click to expand...

My bet would be on B. I'm confident the 80 hour cap will remain in place and not be lowered. The big question in my mind is where the consecutive hour cap will come--will they decrease it from 24+6? If they do, my call schedule becomes fairly unworkable without having all of the residents not on vacation and not on night float work some part of each weekend.

I see many headaches in my future (after 7/1/11).
 
tinyT said:
http://www.acgme.org/acWebsite/dutyHours/dh_index.asp


link isnt live yet, but this looks like where it will be
Click to expand...

based on quick read. pretty much as expected and not too dramatic.
shift limit of 16 hrs for PGY1 and 24hrs for PGY2 for patient care.
plus caveat
"It is essential for patient safety and resident education that effective transitions in care occur. Residents may be allowed to remain on-site in order to accomplish these tasks; however, this period of time must be no longer than an additional four hours."
duty hours stay at 80hrs but with a lot of flexibility in language (if resident deems it necessary, he can stay longer)
 
This document is full of loopholes, the specialties that were worried about not being able to work enough should be very happy.
 
What is everyone's take on the changes to the supervision section, most specifically the requirement of pgy-1s to have direct supervision immediately available and for all residents and faculty to clearly explain their roles to patients?
 
Why is that document dated from Feb 11, 2007? Did they really come up with that 3 years ago and are just now releasing it?

My favorite part.... "Strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 p.m. and 8:00 a.m., is strongly suggested." Like I don't try to take a nap during this time, but instead I'm getting paged about K's of 3.4 and asked if its ok to give somebody dulcolax.

The 16 hour rule for interns pretty much forces everyone to go to shift work doesn't it?
 
ranmyaku said:
W
The 16 hour rule for interns pretty much forces everyone to go to shift work doesn't it?
Click to expand...

It's not a 16 hour rule any more than the current rule is a 24 hour rule. Actually I guess it's unclear if the "4 extra hours" would still apply to PGY1s like the current "6 extra hour" rule does.

Honestly at first glance this looks ridiculous. It's a small enough change not to meaningfully improve the life of interns but big enough to ruin the current system and I can't see any likely alternatives that won't make life suck a lot more as a senior resident.
 
Last edited:
The major changes I saw and my thoughts (<2 cents value) are as follows:

In-house call becomes more restricted. "16 hour" max (+4) shifts for PGY-1s with 10 hours off. 14 hours off after max "24 hour" (+4) PGY-2 shifts. However, one *can* shorten the 10 hours off to 8 hours if necessary. My prediction: this is left wide open for abuse.

Home call is very loose. The hours you're in the hospital count towards 80 hours, but the home call does not count towards work hours, shift length, minimum time until next shift, or number of times you may have call. No restriction on frequency of home call. So you could conceivably be on home call every night.

My prediction: A lot more reclassification of in-house call to "home call". The interns and residents will still spend much of the night in the hospital and not sleep. Whether or not they go home or even should go home is up for debate. In busy hospitals, the intern on call doesn't sleep much if at all, so why even go home and come back? Perhaps even more frequent home call will be scheduled to provide coverage, which will interrupt resident sleep further since you'll practically be on call every night and can't sleep through the night.

If the ACGME is serious about frequency of call restrictions, shift lengths, and minimum time off between shifts, they need to restrict home call as well. Perhaps this could be achieved by putting a maximum in house time during home call shifts. There should be a limit to frequency of home call shifts.

Naps during 24 hours are "strongly suggested". That will essentially be ignored since it's not required.

Up to 4 hours may be scheduled for transfer of care on top of 16/24 hour shifts. I've seen Nasca speak and he's upset with the following. The 30 hour shift rule was supposed to be 24 hours of work and 6 hours for handoffs, education, and *rare* times when patient care demanded more than 24 hours. Most programs abused the heck out of this by making it 30 hour shifts and then frequently violating the 30 hour rule with handoffs, education, and additional patient care.

It's very common in many specialties for the last 6 hours of the 30 hour shift to go towards clinic. They've specified you may NOT spend your +4 hours in continuity clinic, probably because of how common that was. But, what is their intent here? Programs will put their residents in clinic and just not call it continuity clinic. They'll just see new patient instead. If they mean residents should not be taking care of patients or in clinic past the 16/24 hour shifts, they should specify no clinic or patient-related activities period except in rare critical circumstances.

No more than 6 night float shifts in a row. A little more humane than some of the 26 days on + 4 off schedules that exist out there.
 
ranmyaku said:
Why is that document dated from Feb 11, 2007? Did they really come up with that 3 years ago and are just now releasing it?

My favorite part.... "Strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 p.m. and 8:00 a.m., is strongly suggested." Like I don't try to take a nap during this time, but instead I'm getting paged about K's of 3.4 and asked if its ok to give somebody dulcolax.

The 16 hour rule for interns pretty much forces everyone to go to shift work doesn't it?
Click to expand...

I followed the link labeled new at the top of that page.

On the subsequent page (http://acgme-2010standards.org/), click on "Click here to view the proposed standards."

That's got all the new, gory details in underlined and strikethrough form.
 
You must log in or register to reply here.

Similar threads

K
ACGME Survey and implications
Replies
5
Views
4K
mido114
mido114
DrMetal
New DO schools, new residency programs/spots?
Replies
18
Views
4K
j4pac
j4pac
J
  • Locked
Can a person finished a ACGME accredited PGY-1 training apply a new residency position through ERAS?
Replies
3
Views
2K
GoSpursGo
GoSpursGo
Saddleshoes
The WELCOME to your new program???
Replies
8
Views
3K
Top Gun
Top Gun
U
Necessary to include short term position on CV
Replies
14
Views
1K
gutonc
gutonc
Top