ACGME Duty Hours and Common Program Requirements July 2011

[the fat man]

quick question for aPD (or anyone who's involved in scheduling housestaff):

Is there any possible way to implement all these changes without double-punishing the current intern class over the long run? Meaning the intern class of '11 has to work under the old work hour policies which still allow for severe front-loading, and then gets bait-and-switched with this new system where senior residents will now need to pick up the slack from limiting intern hours. Especially as the current intern class will become the juniormost residents in July, who typically still have a more demanding schedule than the seniors and therefore would bear more of the brunt of the workload shifting.

I'm going to an advanced specialty, where there are no interns so none of this stuff will apply (and in my the 24+4 generally won't either since my advanced program already has a hard 24 hour cap for on-call), so for me it's purely academic. But still I'd hate to see my categorical buddies take it up the you-know-what twice.

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[NotAProgDirector]

quick question for aPD (or anyone who's involved in scheduling housestaff):

Is there any possible way to implement all these changes without double-punishing the current intern class over the long run? Meaning the intern class of '11 has to work under the old work hour policies which still allow for severe front-loading, and then gets bait-and-switched with this new system where senior residents will now need to pick up the slack from limiting intern hours. Especially as the current intern class will become the juniormost residents in July, who typically still have a more demanding schedule than the seniors and therefore would bear more of the brunt of the workload shifting.

I'm going to an advanced specialty, where there are no interns so none of this stuff will apply (and in my the 24+4 generally won't either since my advanced program already has a hard 24 hour cap for on-call), so for me it's purely academic. But still I'd hate to see my categorical buddies take it up the you-know-what twice.

There are several options that don't create a "screwed class":

1. Moonlight extra shifts that are created
2. Take elective time away from interns next year to cover new shifts.
3. Increase the size of the resident class, to spread the work more broadly.
4. Completely uncover services where teaching is poor, and then redeploy those residents to fill holes on other services.

I'm sure there are other options.

 

[tibor75]

I'm not a surgeon but given the schedule I've seen some of our trauma attendings keep "irregular and extended" can be quite scary.

Agreed. And the residents of today won't be prepared given their light and coddled schedule. They will quickly realize "work requirements" don't pertain to attendings. They will quickly realize that thinking on your feet with no sleep is an acquired skill...a skill they haven't come close to mastering with their joke of a "16 hour" shift residency.

 

[Ronin2258]

Agreed. And the residents of today won't be prepared given their light and coddled schedule. They will quickly realize "work requirements" don't pertain to attendings. They will quickly realize that thinking on your feet with no sleep is an acquired skill...a skill they haven't come close to mastering with their joke of a "16 hour" shift residency.

There are a few possible options I can see, though one may be more fanciful than the others:

1. Current housestaff are going to be rudely awaken when they become attendings at the hours they normally keep (my attendings definitely worked worse hours than the residents.) (Most likely to happen.)

2. Current housestaff, as the hours increase through their residency, (16 hours for interns, then 24+4 calls in later years,) will become gradually acclimated to working attending hours. It would replace the trial by fire/tossing into the deep end of the pool, "Hello, welcome to your first day as an intern. You're on call today for 36 hours, there are 3 incoming traumas, and 50 patients on the floor that have to be seen. Good luck!" (probably what ACGME is trying to avoid.)

3. Current housestaff, when they become attendings, may push for fewer hours to work as attendings. This may be a pipe dream on some of the good stuff, but it may force change across the spectrum.

Thoughts?

 

[Bobblehead]

It simply defers the culture shock a few years. Bottom line, there isn't enough money in the healthcare system to hire all of the people needed to permit people to work "less" hours. Someone will need to do the work and it can be a pretty rude awakening when you're the attending and after all the clinical work is done you get to do all the things you're now expected to do in addition to the day's workload.

 

[Law2Doc]

There are several options that don't create a "screwed class":

1. Moonlight extra shifts that are created
2. Take elective time away from interns next year to cover new shifts.
3. Increase the size of the resident class, to spread the work more broadly.
4. Completely uncover services where teaching is poor, and then redeploy those residents to fill holes on other services.

I'm sure there are other options.

#1 and #3 are not going to be an realistic option for most places which simply don't have the money to pay for more moonlighting or the "option" to increase the number of residents. And similarly #4 is not an option because again you need employees to cover services, be they residents or some other option which again will cost money, benefits and the like. Programs simply don't have spare cash to make adjustments, so they will be trying to adjust the schedule of interns/residents who come with their own funding and already have been committed to by virtue of being a teaching hospital.

I think you absolutely will see interns lose many of the cushy elective months, and hospitals will now find ways to milk a full 80 hours/week out of interns even without the 30 hour shifts -- and IMHO they are now more likely to hit the full 80 each week because of need for man hours thanks to these new "go home and sleep" regulations.

But at least for the next few years of implementation, I don't doubt that this same class of rising interns is going to get abused because they are getting caught between the two rules -- they were stuck with 30 hour shifts and now are the least senior of the folks that don't have the intern 16 hour restrictions, so they will again bear the brunt.

But in the long run they can take solace that future interns will probably have it worse than them because thanks to the new rules, although they will get home each night, I suspect the next crop of interns will work 80 hours per week average thanks to loss of electives, while the prior crops often got away with chill derm/rheum months of 50 hours here and there.

 

[Law2Doc]

It simply defers the culture shock a few years. Bottom line, there isn't enough money in the healthcare system to hire all of the people needed to permit people to work "less" hours. Someone will need to do the work and it can be a pretty rude awakening when you're the attending and after all the clinical work is done you get to do all the things you're now expected to do in addition to the day's workload.

Agreed. They are going to need at least the same man hours whether it be 30 hours in a row or some other format. Expect places to max out the 80 hours/week for interns somehow.

 

[Winged Scapula]

And similarly #4 is not an option because again you need employees to cover services, be they residents or some other option which again will cost money, benefits and the like.

While I agree with everything else you've written, the above may be feasible.

I liken it to my personal experience where residents were permanently pulled off a subspecialty rotation during 3rd year because of the complaints about poor teaching, favortism given to the PA on service (in terms of cases), etc. Once it was deemed that we had done the required amount of hours on that service as an intern, the residents were pulled and not required to do that rotation anymore.

The subspecialty department (CT Surgery if anyone is interested) was then left to find someone, anyone to cover their service and cases. The GS department was not required to provide them with residents to cover their cases and now residents were able to cover other services more deeply and get better teaching and a better overall experience.

I'm not sure if this is the case with other specialties (where the "parent" specialty might be required to provide residents on certain rotations), but its worth considering.

 

[Allygator89]

#3 doesn't really work either. If you expand the class for 2011, and change the schedule to meet the requirements, you are now expecting the current intern class to have to pick up the slack over the next two years while your program "ramps up" to the increased size... so their class will always be at a disadvantage.. at least until they graduate. The only way around this option is to take people that are trying to find PGY2 spots from other programs, but that has its own challenges....

 

[J ROD]

I am not in residency or even near it, but do these changes simply mean one will not work as many hrs straight but still work more days since they still will be worked to the 80hr max?

Basically, they protect interns more and make those 30hrs shifts obsolete.

 

[Winged Scapula]

I am not in residency or even near it, but do these changes simply mean one will not work as many hrs straight but still work more days since they still will be worked to the 80hr max?

Basically, they protect interns more and make those 30hrs shifts obsolete.

Yes.

 

[Law2Doc]

...
Basically, they protect interns more and make those 30hrs shifts obsolete.

Sure, but probably at the expense of cushy electives and other nice "perqs" some get during intern year, as well as likely translating to harder shifts as a second year and beyond.

Also probably means every program is going to have blocks of night float, since a lot of the q4 or q5 systems don't work well with only 16 hour shifts. The catch here is that many programs with night float take the position that there is no real need for you to sleep during a night float shift (as compared to overnight call) since you aren't needing to be in the hospital for 30 hours any longer, thus places may expect you to work the whole night, which means you lose the next day sleeping. This is very different from an overnight call where you might be able to grab a few hours of sleep in the call room if you are lucky and still enjoy most of your postcall day. Instead you are going to come home in the am, go to sleep for the bulk of the day and be expected back for night float the next night. Trust me, you won't find that better.

 

[Orbo]

Sure, but probably at the expense of cushy electives and other nice "perqs" some get during intern year, as well as likely translating to harder shifts as a second year and beyond.

Also probably means every program is going to have blocks of night float, since a lot of the q4 or q5 systems don't work well with only 16 hour shifts. The catch here is that many programs with night float take the position that there is no real need for you to sleep during a night float shift (as compared to overnight call) since you aren't needing to be in the hospital for 30 hours any longer, thus places may expect you to work the whole night, which means you lose the next day sleeping. This is very different from an overnight call where you might be able to grab a few hours of sleep in the call room if you are lucky and still enjoy most of your postcall day. Instead you are going to come home in the am, go to sleep for the bulk of the day and be expected back for night float the next night. Trust me, you won't find that better.

Indeed...even with my limited night float experience I can already agree with the notion that it's pretty much stay-up-all-night-come-home-in-the-morning-sleep-the-whole-day(6hrs)-then-wake-up-and-go-straight-back-to-the-hospital. Rinse and repeat everyday for a week or more. It's not very fun.

 

[Dwindlin]

As strange as it sounds I for one was actually looking forward to the 24+ hour shifts...I honestly wish you could just sign a waiver accepting the slave labor life.

 

[deuist]

I agree. I also think it's silly that MD or DO's with 1-2 years residency and USMLE can't easily get midlevel-type jobs. I don't see why someone who has passed USMLE 1-3 and has at least an internship should not be considered as competent as a graduating PA or NP. It's fundamentally unfair.

I sent a letter to my state rep a few years ago about this very issue. I wrote that anyone who had completed 3 years of medical school and STEPs 1 and 2 should be licensed as a PA. I never heard back from him.

 

[deuist]

Sure, but probably at the expense of cushy electives and other nice "perqs" some get during intern year, as well as likely translating to harder shifts as a second year and beyond.
.

What cushy electives are you referring to? This must be an IM thing. When I did surgery last year, the closest thing to a cushy rotation was colo-rectal surgery, which meant that we got to eat lunch on most days and were usually out of the hospital on time.

I don't see these new rules hurting surgical training as PGY-1's rarely do anything resembling surgery. All of the operating comes in PGY-2 and higher, where the hours are not changing---except for the chiefs where the hours might be increasing.

 

[mohderm]

It seems to me that the only residents who find fault with night float are those who have not been exposed to it. As a medical student I was at a program with long call (30 hours q4-5). I know I was only a student, but as a Junior Intern 4th year I did it for a month. Currently I am at a program as an intern with night-float and it's great. I can say this because I have already completed my month of nights. It was 7-7, Sunday-Thur with all weekends off. The weekends were covered by residents from those "cush" electives you were talking about. So the way it works out is you do a month of nights each year and then maybe 5 additional weekend nights throughout the year. Yeah your schedule is off for that month, but for someone who despised the overnight 30 hour shifts it was awesome. I'm essentially done with overnight call and I'm a third of the way finished with intern year.

 

[Winged Scapula]

It seems to me that the only residents who find fault with night float are those who have not been exposed to it.

I'm glad its worked out well for you but there are problems with night float.

Surgical residents will miss out on cases performed during the day (and most of the night cases as well because the attendings will not want to be doing an emergent case in the middle of the night with an intern). Although in deuist's programs interns don't operate much, at many others, the interns are doing cases, especially hernia repairs, lumps and bumps, etc. These are done during the day and they miss out on that.

Other programs may have more than 1 month of night float so you aren't necessarily done with overnight call after 1 month.

Lastly, for many people the sleep wake disturbance is pretty debilitating.

NF may be a necessary evil but its hardly benign in many cases.

 

[Cirrus83]

1. More prelim interns. They may be going into surgery they may not, who cares? We won't keep them on any longer than intern year thats for sure. So....we get more prelims, then we drop them the next year. Who benefits there? Hours restrictions don't hurt us but sure don't help the interns

If every hospital tries to get more prelims then I don't really see how anybody's really going to get more prelims. Seems like it's going to be limited by the supply side-I'm not really sure how you're going to conjure up lots of surgical prelims out the blue.

 

[Cirrus83]

2. Current housestaff, as the hours increase through their residency, (16 hours for interns, then 24+4 calls in later years,) will become gradually acclimated to working attending hours. It would replace the trial by fire/tossing into the deep end of the pool, "Hello, welcome to your first day as an intern. You're on call today for 36 hours, there are 3 incoming traumas, and 50 patients on the floor that have to be seen. Good luck!" (probably what ACGME is trying to avoid.)

That definitely sounds like what they're trying to achieve. Interns get better and better at doing things more quickly as they gain experience and handle heavier loads a lot better over time. The continuous hours will just have a learning curve built in.
Still, I'm not sure if it's more or less grueling to do 16 hours but never get post-call days.

Surgical residents will miss out on cases performed during the day (and most of the night cases as well because the attendings will not want to be doing an emergent case in the middle of the night with an intern). Although in deuist's programs interns don't operate much, at many others, the interns are doing cases, especially hernia repairs, lumps and bumps, etc. These are done during the day and they miss out on that.

I have to admit that I was thinking the same thing as deuist-that the 16 hour rule wouldn't really affect the training of surgical interns that much just because they don't really get to do that much, so even if they're missing out on surgeries they're often just missing out on doing the same stuff medical students do. But obviously in programs where interns actually got to do a lot it'll be different. Still, at least from what I've seen, attendings actually let interns do more on cases that came in during the night. Maybe this was partly just a matter of manpower (i.e. if multiple surgeries are going on in the middle of the night) but I actually think that once the really emergent stuff was under control they let the interns do more than they got to during the daytime-kind of a reward of sorts for being on call? I know all this stuff is going to vary heavily depending on the program but I think if you average it all out you won't have any negative effect.

Overall I don't think the sky is going to fall or anything. I'm not sure if things will really be any *better* but it really doesn't seem to be some kind of medical apocalypse, and I doubt that any surgical residency is going to have to add a 6th year because the interns didn't get to retract and suture the skin quite as often that first year.

 

[Law2Doc]

...
Other programs may have more than 1 month of night float so you aren't necessarily done with overnight call after 1 month.
....

Agreed. I know someone who had 13 weeks of night float, broken up into 1 to 4 week blocks over the course of the year, plus about a dozen 30 hour weekend call shifts. While conceptually it's nice to get it done and not have call every 4th day, you can have this hanging over your for much of the year at a smaller program. Plus, as mentioned, you don't get to enjoy "post call" days on night float at some places because you are expected to be up all night every night while on night float since you are really just working a day schedule during reverse hours (not really the case with call). That being said, I think it's not a bad system -- it takes a few days to get used to the new schedule, but sometimes things go your way and everybody stays stable and quiet throughout the night, and night float gives you a ton of independence because most of your superiors will be home in bed and most will want you to only call them as a last resort (regardless of what they tell you).

 

[Law2Doc]

...
I have to admit that I was thinking the same thing as deuist-that the 16 hour rule wouldn't really affect the training of surgical interns that much just because they don't really get to do that much, so even if they're missing out on surgeries they're often just missing out on doing the same stuff medical students do. But obviously in programs where interns actually got to do a lot it'll be different. Still, at least from what I've seen, attendings actually let interns do more on cases that came in during the night. Maybe this was partly just a matter of manpower (i.e. if multiple surgeries are going on in the middle of the night) but I actually think that once the really emergent stuff was under control they let the interns do more than they got to during the daytime-kind of a reward of sorts for being on call? ...

As WS suggested, at the smaller community residencies, interns are in the OR daily, and not the same stuff medical students do (many still have med students there as well, working under them and doing the retraction). It's mostly the larger academic places that sentence the interns exclusively to floorwork. Partly it's a matter of staffing - it takes fewer people to man the floors than to staff the ORs. Partly it's that the smaller places do a ton of routine stuff (lots of horses, never zebras), and so you get thrown in on the hernias and lipoma removals and OR debridements -- the nonglamorous things that attendings would otherwise do with their eyes closed.

But I do agree with you that if you are there at off hours and something comes in, you will get to do more. It's the reason you still want to show up at work during bad snowstorms, and the reason it's nice to be the only resident there overnight when something cool comes in the door. Attendings in such circumstances absolutely tend to throw the helper a bone. So WS is right that you miss out on 95% of the cases. But on that remaining 5% you probably get to help run the show in a big way. Still not an even trade, but better than nothing.

 

[deuist]

If every hospital tries to get more prelims then I don't really see how anybody's really going to get more prelims. Seems like it's going to be limited by the supply side-I'm not really sure how you're going to conjure up lots of surgical prelims out the blue.

Supply side isn't the problem. There are loads of FMG's who are eager to train in the U.S. I just don't see hospitals as being willing to pay for any more personnel.

 

[Winged Scapula]

Hospitals can't just add residents, preliminary or not. There is a cap on the number of residents that are funded by CMS. Thus, while it sounds like a great idea to hire more residents, it is a lengthy process which requires approval of ACGME and RRC. Programs have to be able to prove the have enough work to support the additional position (my residency program tried for years to get another spot; I see they finally have one this year). Funding would have to come from other sources than CMS unless another program in the same hospital gave up a resident.

And while YMMV, I found attendings *less* likely to do cases in the middle of the night with an intern. More than once I was called in, as a senior resident or Chief to do a case, and more than once as an intern, I was told, "the attending won't do the case at 0300 with an intern." They want to get in and get out. Obviously when it was an issue of manpower (multiple traumas requiring ex-laps) the attendings would take what they got. It will take a sea change/mind-set change for a lot of attendings to use the in house NF junior resident when, especially at bigger programs, there will be a senior in house or someone at home close by they can call in. So this idea presumes that attendings will do the case with the in house junior resident/intern.

 

[microscp2]

currently, I am doing my internship. My program just announced that they will change the schedule starting in January, to switch to the 16 hours. I am so happy, in my hospital you dont get to sleep when on call, since is so busy.

 

[dpmd]

What cushy electives are you referring to? This must be an IM thing. When I did surgery last year, the closest thing to a cushy rotation was colo-rectal surgery, which meant that we got to eat lunch on most days and were usually out of the hospital on time.

I don't see these new rules hurting surgical training as PGY-1's rarely do anything resembling surgery. All of the operating comes in PGY-2 and higher, where the hours are not changing---except for the chiefs where the hours might be increasing.

It really depends on your program. At my program the interns operate a lot (and it is legitimately operating although with verbal guidance), by the time we are halfway through our second year we are expected to be prepared to be the senior surgeon in house covering all surgical specialties (meaning when that cric or ED thoracotomy needs to be done, you need to have the confidence and dexterity that comes from having done other operating-as well as the knowledge that you likely only picked up from reading and skills labs). The way they get there is that they are operating during the day with attendings (or the chief resident) and overnight they are dealing with whatever rolls through the door, with the night float senior teaching them and guiding them. The chief resident is at home on call (essentially every other night since we only have two), as is the attending-so you can call for advice but they can't physically help you until they drive in.

Since we are a small program and a small hospital we actually do have some rotations that are helpful but have much nicer hours (SICU since it is a consult service only, anesthesia, GI, neuro can go either way but it has home call, ortho used to be cush but now more call since a few of the PA's left). It really wasn't even that bad when we had call (sometimes got sleep, mostly did not, but got out at reasonable times post call unless you wanted to cheat and stay for a good case). As the chief to be when this is implemented I have been working on some versions of compliant schedules and what it has been looking like is that they are going to lose daytime opportunities and work more hours over the year(no more easy rotations, no more getting sent home early if the day is light since I need to cover nights and clinic-16 hr shifts starting at weird times during the day was one option). Also might not be able to give two days off together anymore, which I think sucks.

 

[MeowMix]

having done plenty of night float and even more 30-hour call, I am quite sure that I despise night float. I get a few hours of poor-quality sleep, I do not see my family/friends for the entire week, I have no life, and it does nothing to improve patient care. On top of that, the commute takes more time and I have to drive more hours. Ugh.

 

[dpmd]

One of the perks of the way we do night float is that we get all four weekends off (friday and sat night). With the new 14hr break after a 24 hr of duty thing I am having trouble figuring how to be compliant without taking away some of the days off, going to a one day off at a time scenario for the people covering those nights (which we would all hat I think), or telling the people covering the friday night not to come in until noon (which is a problem for the people on outside rotations since they will miss out on case, and will further reduce the number of people to cover things in the morning for GS/trauma).

 

[docbill]

The things I am learning about work hours.

Lots of people work 80 hrs / week. Some work over 80 hours / week over 4 weeks. They are just not allowed to report the hours. Some take their work home with them, with logging on to medical system from home.. to do D/C and orders. Some don't count pre-rounding in the morning as part of their hours or paper work after they sign out.

If you do report the hours then you are told that you are not being efficient and you are not at par with the other residents and your evaluations will also agree with poor performance.

 

[docbill]

The biggest joke seems to be the 10 hours off between shifts.

 

[Boba Q Fett]

The biggest joke seems to be the 10 hours off between shifts.

Pretty sure this is already a rule. The biggest joke is "strategic napping."

 

[KYTNOH]

The old system of no work hour restrictions was detrimental to education, life, and quality medicine. The current system with 80 hour workweeks and 30 hour max shifts seems to have made it much more humane without dramatically decreasing the amount of learning. The forthcoming system will possible necessitate increased residency lengths and possible a worse lifestyle. As an intern I didn't mind q3 call with a "short, call, post" setup. Sure, the 30 hour call sucked, but then you're post-call and the next day you have a short day and one day a week off completely. What interns will go to is 15-16 hour days 6 days a week which I would absolutely hate. You'll have 8-9 hours off in order to "live." That's tought to do. I would much rather go all out for 30 hours and then have a decent schedule for two days.

Unfortunately, rules like this happen when we let people 20 years removed from real practice suggest the rules (speaking specifically about the Institute of Medicine since all of this originated with them).

I'm doing Emergency medicine and will be a third year next year. As such I won't be affected by this at all since I will essentially be in the ED without exception. I feel bad for our interns though.