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ACGME duty hours conference in March

Discussion in 'General Residency Issues' started by exPCM, Jan 6, 2009.

  1. exPCM

    exPCM Membership Revoked
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    http://www.acgme.org/acWebsite/newsReleases/newsRel_12_2_08_IOMreport.pdf
    "The ACGME is appreciative of the work done by the Institute of Medicine to study the
    impact of the common duty hour standards on resident learning, resident well-being, and
    patient safety. In early March 2009, the ACGME is convening a duty hours conference
    that will bring together leaders in graduate medical education from around the world. The
    conference participants will carefully review the IOM report as part of discussions on
    possible refinements to the duty hour standards."

    My contacts indicate that some adjustment in work hours is likely.

    Here is a link to the IOM report:
    http://www.iom.edu/?ID=60449
    These were some of the IOM recommendations
    Duty hours must not exceed 80 per week, averaged over 4 weeks.
    Scheduled continuous duty periods must not exceed 16 hours unless a 5-hour uninterrupted continuous sleep period is provided between 10 p.m. and 8 a.m. This period must be free from all work and call, and used by the resident for sleep in a safe and sleep-conducive environment.
    The 5-hour period for sleep must count toward total weekly duty hour limits. Following the protected sleep period, a resident may continue the extended duty period up to a total of 30 hours, including any previous work time and the sleep period.
    Residents should not admit new patients after 16 hours during an extended duty period.
    Extended duty periods (30 hours that include a protected 5-hour sleep period) must not be more frequent than every third night with no averaging.
    After completing duty periods, residents must be allowed a continuous off-duty interval of a minimum of 10 hours following a daytime duty period that is not part of an extended duty period, a minimum of 12 hours following a night float or night shift work that is not part of an extended duty period, and a minimum of 14 hours following an extended duty period; and residents should not return to service earlier than 6 a.m. the next day.
    Night float or night shift duty must not exceed four consecutive nights and must be followed by a minimum of 48 continuous hours off duty after three or four consecutive nights.
    At least one 24-hour off-duty period must be provided per 7-day period without averaging;
    one additional (consecutive) 24-hour period off duty must be provided to ensure at least one continuous 48-hour period off duty per month.
     
    #1 exPCM, Jan 6, 2009
    Last edited: Jan 6, 2009
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  3. daru1

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    With all due respect, did your colleague give any suspected timetable on implementation on any duty hours changes?
     
  4. bluealiendoctor

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    With all due respect, the current guidelines are not being enforced whatsoever, what makes anyone think new ones will be?
     
  5. dynx

    dynx Yankee Imperialist
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    I hope to god Im no longer a resident when this gets pushed.
     
  6. aProgDirector

    aProgDirector Pastafarians Unite!
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    Buried in the IOM site is this link to the report's "executive summary" Although it's 39 pages long, it at least describes all of the recommendations of the IOM group.

    The ACGME will be discussing this at their March 2009 meeting. No exact timetable for implementation has been discussed, although the IOM recommends that all changes be in place within 24 months. They of course have no way to pay for all of this, they simply ask all of the current major payers to get together and figure it out.

    Another link of note: the ACGME is offering a web based survey to get med student, resident, faculty, and PD input. The survey closes on Jan 10. If you choose to complete it, you will see that two of the 5 pages (I believe it's pages 3 & 4) are ridiculously long. You can leave these blank, skip to page 5, where there is a plain text box for entering any comments you wish. Feel free to tell them what you think.

    I expect that changes will be the following:

    Very short term: we will see more strict enforcement and monitoring of work hours.

    Short term: Moonlightiing will become subject to all duty hour rules, and days off will be increased. Both of these are relatively "easy"

    Long term: 5 hour naps, 16 hour shifts, and 10/12/14 hour breaks. Some may never get fully implemented.

    I don't fear the ACGME. At least they'll listen to me, and the surgeons will scream about all this. I worry about the Joint Commission and congress. If either of them get into this game, there will be no stopping it.

    I'm all for making residency better and decreasing abuse. I'm not convinced that 24 hour call is really a good thing. I'm just not sure that this is the right way to fix it.
     
  7. Long Dong

    Long Dong My middle name is Duc.
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    So are residencies just going to get longer then?
     
  8. waldenwoods

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    How did you hear of the survey? Just curious. As a med student, I didn't get any e-mail or snail mail notification of this survey.
     
  9. PeepshowJohnny

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    Very well put.
     
  10. 3dtp

    3dtp Senior Member
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    I'd like to believe this. I really would, but I think you hit the nail on the head above: ". . .recommends that all changes be in place within 24 months. They of course have no way to pay for all of this. . ."

    Unless and until such time as programs/hospitals no longer maintain their schizophrenic attitude toward residents (ie nearly free labor v. physicians in training), institutions who are so inclined will not willingly do this. The more malignant programs will encourge in subtle or perhaps not so subtle ways, dishonesty in hours reporting.

    Yet, this is precisely what needs to happen. I could care less about 80 hours and 1:7 off. My body on the other hand, insists on a reasonable sleep period on a daily basis. One institution was able to accomplish close to this by splitting the night between intern teams. One intern took the "early" shift and worked 11-3 then went to sleep, and the other picked up the 3-7 "late" shift while the first slept. Then the regular daily routines began. There are solutions.



    I agree. However, the only way to stop it is for medicine to clean up its act.

    I agree with you.

    But, the IOM is correct in this case. I think the easiest fix is to give hospitals the incentive to properly assign value to their labor pool. The only way to do this is to allow residents to change residencies in a reasonable manner if they find themselves in a bad program, and vice versa. Then, there would be less need for direct rule making since bad programs will quickly become known and if they want to attract the residents they want, they will have to clean up their act and make it known. The end result will be an improvement in working conditions for everyone, and I believe a happier, healthier, more motivated residency corps.

    These recommendations are not pulled out of hats. They are the result of some knowledge of sleep hygiene and have been tested over the past 100 years or so. These recommendations are generally nearly the same as the requirements listed in 14 CFR 135 Subpart F. (135.265, 135.266, 135.267).

    These rules require time on duty not to exceed 8 hours for a crew of 1, 10 hours for a crew of 2, and rest periods of 10 hours between on-duty times.

    These regulations do contain provisions for exceeding work rules limitations if delays or duty requirements cause the hours to be exceeded beyond the control of the organization, but they also carry a sanction: if duty hours are extended beyond the maximums, even if beyond the control of the company, then the rest periods are appropriately extended.

    What this amounts to is a cumbersome and complicated set of record keeping and duty hours monitoring. This is the downside and its a royal pain. The upside is that since we enacted these regulations in this sector, the "mistake/accident" rates plummeted.

    The IOM is being generous (and reasonable in my opinion) by mandating a maximum of 16 hours on duty. 10 hours is a reasonable rest period, given what we know about sleep requirements of mammals.

    The problem is that prior to the threat of legislation by Conyers/Wellstone in 2001/2002, the ACGME and institutions gave lip service to the hours limits, even those enacted by law in NY and RRC rules, which one PD brazenly told me that "RRC rules don't apply to this hospital. The needs of the hospital come above the RRC rules." This phrase and that attitude is etched into my memory forever. It is wrong. It is unjustified. It cannot be made right. And the worst: it teaches precisely the wrong lesson.
     
  11. daru1

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    YES!!! Finally, another pilot using 135 logic, I thought about saying something before, but it wouldn't have been near as eloquent.
     
  12. KidDr

    KidDr Senior Member
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    very well said, 3dtp.
     
  13. Long Dong

    Long Dong My middle name is Duc.
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    So how are they going to do all of this make residencies longer. IM going to be 4 years now that you need your naps, and surgery already 7 at some places going to be 9-10.
     
  14. dragonfly99

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    <I think the easiest fix is to give hospitals the incentive to properly assign value to their labor pool. The only way to do this is to allow residents to change residencies in a reasonable manner if they find themselves in a bad program, and vice versa. Then, there would be less need for direct rule making since bad programs will quickly become known and if they want to attract the residents they want, they will have to clean up their act and make it known. The end result will be an improvement in working conditions for everyone, and I believe a happier, healthier, more motivated residency corps. >

    I agree with this. If it wasn't damn near impossible to switch residencies, I think residents would get treated better. I was at a good program and we were generally treated decently, but I shudder what things are like at some crappy internal medicine residencies...I truly do.

    Longdong, I just got done doing IM not that long ago and I don't see why IM residency would need to be made longer with these proposed changes. I don't agree with all of them, but I think there are more good than bad suggestions. Really, having either 24 hours total duty time or some mechanism to create a way for interns to have a few hours rest in the midst of a 30 hour shift (instead of taking more admissions or just 3 a.m. nurse pages about tiny problems in the chart/orders written by some other intern 12 hours ago) would not decrease the learning. It would likely increase the total amount of learning since the interns would be less zombielike on teaching rounds or in morning report later that morning. Surgical residencies are a different case...however, I still think they could teach them to operate in 6 years...but I am not a surgeon so I digress.
     
  15. Miami_med

    Miami_med Moving Far Away
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    The biggest problem in surgery residencies seems largely to be that you need a lot fewer people covering a lot more patients in order to get all the people enough cases to be proficient. This often leaves very little logical backup in surgical training slots. This makes "naps" difficult.

    It also makes absolute time off requirements difficult to comply with, because you can't predict when cases will end. It would essentially mean that everyone trying to stay late to do a case would not be able to attend morning rounds. Surgery residents largely WANT to be able to stay late to do cases.

    Surgical residents are already used to having to fight with pet PAs and NPs for cases at some places, and there is some objection to further utilizing these sorts of mid-level providers. Surgeons still need to learn a lot of medicine, and you don't want to turn overall of the floor to the mid-level.

    Basically, the distribution of floor work per unit to OR case time per unit is such that operating enough to become proficient generates an amount of floor work that doesn't lend itself well to work hour restrictions. This limit is already being tested by the current rules in many places. The "naps" will make trauma coverage something of a disaster. Since there is usually only one attending trauma surgeon in house at night at many major centers, it will usually force the 30 year old resident to nap so that the 60 year old attending can stay up all night.
     
  16. aProgDirector

    aProgDirector Pastafarians Unite!
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    As a PD, the ACGME oversees my program. They emailed me. I assumed they somehow distributed it to students. Apparently not.

    Nope. Costs too much for the Fed Gov't. And, if IM went to 4 years and FP stayed at 3, it would be bad for IM. And, there is no way that the fellowships would tolerate another year delay. So this ain't happening -- at least not in IM.

    I'd like to think that I happen to run one of those programs that actually cares about residents and doesn't just abuse them, but I agree that if programs see residents as simply free labor, they will get as much work out of them as possible regardless of the rules.

    One of the suggestions of the IOM task force, not talked that much about, is developing an independent monitoring body -- recognizing that the ACGME shouldn't really be the watchdog for duty hours, as they are somewhat conflicted.

    It's a great idea, assuming that the number of patients covered by each intern is reasonable. If each intern is assinged to cover 30-35 patients, but then when they sleep they each cross cover 70 patients, you've just traded one problem for another.

    I agree with you that 24 hour call is bad. I have been trying to move to a more night float type system, with much resistance. From the residents themselves.

    What exactly is stopping residents from changing programs?

    1. Contracts -- most contracts have some sort of "notice" clause. Requiring 60-90 days notice seems reasonable, although an argument for 30 days notice could be made.

    2. Funding -- programs are funded and credentialed for a specific number of spots. I can't just take an extra person if I want to, unless I have an open spot. So if you want to leave your position, you can't simply be hired anywhere else. Since most spots are filled, there is a very low "open jobs" rate which makes it difficult to change programs.

    3. Fear -- this is probably the biggest problem. If a resident leaves another program midstream, and tells me it's the program's fault, I think of two things: 1) It's really the resident's problem, and 2) if the program is really that bad, this resident is going to be way behind. Either way, these cases can be a huge problem, since once the resident starts in my program they're now my problem

    The comparison to aviation is made often, and is somewhat reasonable. There is no question that duty hours for pilots and other safety changes (i.e. checklists) have greatly decreased accidents and errors. However, the comparison has some problems: The main problem is basically this: Pilots interact with the plane, whereas physicians interact with patients. If I'm in a plane, I really don't need to meet the pilot, nor do I care if it's a different pilot who flys my return flight. Since the plane is very standardized, the pilot can do his or her job basically the same way each day. Medicine doesn't work that way -- doctors interact with patients. Patients and their families are all unique, and unpredictable. Standardization doesn't really work, and continuity is important.

    Example:I was on a plane once that was delayed, and then finally the crew announced that they were going to be over their hours. So what happened? The flight was cancelled, and I was rebooked the next day.

    Problem is, that doesn't work as well in medicine, as people get sick and they can't just wait until the next day. An example is this: I was just on the inpatient service with one of my teams. We were working a shift -- supposed to admit until 7P, home by 9P. All was going well, until a family came in at 6:30P and wanted to talk about their loved one. We spent quite a while talking to them, and then ended up leaving late. What should be done? We could tell families that we can only talk to them between 3-5P. The team could come in later the next day, but then they miss morning report and their discharges/patient care are all delayed (or someone else starts rounding on their service and their autonomy is undermined). Or we have the night float, who doesn't know the patient well at all, try to answer their questions so we get home on time.

    I'm not sure what the right answer is, and I agree that if people are working too many hours and are too tired, then care gets compromised also.

    Example #2: Birth of my first child. Wife goes into labor. Very excited. Come to hospital. Seen by MD #1. Told all looks good, get ready to be new parents. About 4 hours later, seen by MD #2. Examines wife, her exam is completely identical. Get told that her reflexes are brisk, worried about pre-eclampsia. MD #2 starts Mg. All contractions stop, Pit gets started. 4 hours later, MD #3 comes in. I suggest that maybe she doesn't really need the Mg. I get told that he can't tell me, since he didn't see her on admission. But now her reflexes are fine, so we have to assume that the Mg is needed. Pit's causing her contractions to be more painful, so she gets an epidural. MD #4 arrives (next shift), examines her, says she can't have the epidural because it's somehow interfering with her contractions. But she's not fully dilated yet, so not ready to push. I wonder why the last MD, here just an hour prior, ordered the epidural. MD #4 says they didn't really discuss it, he was just told that she had an epidural and he was here to check it. So the epidural is off. Pain is back for hours. MD #5 arrives and wonders why the epidural is off. Our baby was delivered by MD #7. We had a healthy girl, and all is well.

    But it sucked. Shifts signing out to each other, and knowledge gets lost. There's no way to sign out everything perfectly. And most importantly, it would have been SO NICE to actually see one person in continuity for our baby. Maybe not 24 hours in a row, as everyone need sleep. But I think that in this discussion we can lose the importance of patients bonding with a single physician. It's really important. This team based care stuff is crap. When I'm sick, I don't want a team. I want a doctor to take care of me.

    Honestly, this is the thing that drives me crazy about nursing. We see a patient. I spend 20 minutes talking to the nurse, getting them up to speed on the plan. 4 hours later I get paged. New nurse, same questions. They sign out BM's, IV's, and anything else that can be nicely put in a nursing flowsheet. They have no good way to actually signout knowledge -- because I'm not sure there is one.

    The other problem with shifts is teaching. We have morning report every day. It's the best conference of the day. Problem is, if we create afternoon (swing) and night shifts, you can't go to morning report. And I can't simply create Evening reports -- there won't be enough attendance, etc.

    I agree. I feel that 24 hour shifts are wrong. 16 hour shifts + 10 hours rest = 26 hours, so really the maximum shift is 14 hours.

    The problem in my program is very simple. Most discharges happen in the early AM, but most admissions happen in the late PM. because the hospital is full almost all the time, we can't take outside transfers until the current patients are discharged and the rooms have been "turned over". So, teams need to be here in the early AM to round / discharge, but then also late to admit, and you can't really fit both in. I wonder if the way to address this is to have an "admitting" team who just does admissions, and then "rounding" teams that just take care of the daily needs of patients. This leads to many more handoffs, which is not necessarily a good thing.

    It is wrong.

    I still wonder exactly what the right answer is. I worry that as we create more rules and shifts, we will simply move the responsibility for patient care from residents to others. And in the end, residents will become as disposable as medical students, not have any real responsibility for patient care, and not learn anything. There must be a happy medium somewhere, but I fear overshooting it.
     
  17. 3dtp

    3dtp Senior Member
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    Man oh man, I wish you had run the program I was in! This would have made life better for many people. Can you be cloned?

    I did know about the independent monitoring body. I've suggested this concept myself. The ACGME/COTH/LCME/NRMP are made up of the same people and as such have intrinsic conflicts of interest as you have so eloquently elaborated.

    I'd take this one step further, though. The independent monitoring body should also be the keeper of the records. Such a body would be charged with acquiring from the programs, training records contemporaneously and timely. This way, there is a greater measure of confidence in the accuracy of these records, as an independent body would have no stake or interest in "supplementing" a resident's file for political purposes. Independent maintenance of key training files, evaluations, records, and disciplinary notes would help keep those who might otherwise be tempted on the straight and narrow and would facilitate the transfer of a resident to another program.

    Along with this would be a standardized skill inventory checklist and procedure count which gives an objective (well sort of, since we all know that doesn't really exist) assessment of the skills inventory/objectives.

    The ABIM already does this in synoptic form, which does provide an important second source of data to prevent/reduce record tampering within a program for political reasons. Keeping copies of source documents would be even better. Auditors and security folks are very fond of the two man rule: Custody/access to important documents should never vest in a single person.

    The one problem I see with this is that the FSMB set up a system to do this and it has been an unmitigated disaster. It is cumbersome, untimely, expensive and most states who have tried it are now backing away from it, or find that they have to obtain records the old fashioned way to issue a temporary license until such time as the FSMB can after months certify and send a file.

    Every time we create an "independent [pick your adjective] body" we create yet another bureaucracy which will have to be paid for, and then the golden rules apply (he who pays controls.)

    I agree with all of these. But I think that item 3 is the biggest obstacle. And it is very much a two way street. When I was chief, one of my juniors came to me to tell me about a new program starting, one of his buddies at the institution called and he wanted to scoot. It was definitely in his best interest to go, but knowing the PD he was terrified of the repercussions possible, and, in my mind, likely, if something went wrong. So, we devised a plan, he gave plenty of notice, and things did work out well. He ended up in a program with good training and wasn't used as a servant which would have been his lot had he stayed. Ours is a competitive field, so we were able to re-fill his spot sans difficulty, nearly immediately.

    Sometimes, there are personality/style conflicts that arise. I do think that as programs get better at following rules, things will improve everywhere and that will reduce the need for this discussion, but it hasn't happened yet.


    Oh, my I wish this were true. The plane is standardized, to be sure, but the weather, mechanics, air traffic controllers, routings and congestion are never the same and each flight can be an adventure. I first heard this expression from a buddy of mine who at the time was the wing commander for the Blue Angels, "Flying is hours of sheer boredom, punctuated by seconds of sheer terror." Been there, know the drill. Never bent an airplane, but I sometimes wonder if one more thing had gone wrong would I be here today, along with a plane load of pax.

    My example here is a flight from a northern city to a southern city. Total planned block time was 2h20m. Departure weather was clear visibilities unrestricted. Forcast destination arrival weather was ceilings 800 foot overcast, 5 miles rain and snow. Enroute weather was tops at 18000 clear above, moderate icing in clouds and precip. I requested and got fuel for 4 hours, well within normal standard flight planning parameters. We were flying a commuter that day with good, but limited anti-icing. We launched, had an uneventful climb to clear weather and settled down for what should have been an uneventful flight. We encountered delays in weather around OHare, and further delays at our destination as the weather was much worse than forecast. We had been airborne 3 hours when I decided to proceed to our alternate. The problem was everyone else made the same decision about the same time. And they all had the same gas situation we had. Everyone got down safely, and the passengers had no idea what the real scoop was, but they were not happy we were not where we told them we'd take them. Airplanes and flight manuals are standardized, so are stethascopes and scalpels. Knowing what to do when is another matter.

    Excellent point, well made. But, so are passengers.

    When I read your comments on this board, it renews my faith in the system. If we all tried to do the right thing, checked our egos in the garage, and realized none of us have the best right answer all the time, life would be far better for all of us. Unfortunately, we can't legislate human nature into nice packages.

    Thanks for being a quality program director.
     
  18. Pilot Doc

    Pilot Doc SDN Angel
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    Sure, but no matter how challenging one flight is, it doesn't impact the next flight.

    I'm with the program director on this one. The safety record of airlines owes a lot to the fact that their operations can be standardized many orders of magnitude more than medicine. And in regards to duty hour issues, medicine and aviation are totally different.

    Commercial aviation has zero duty hour issues that extend beyond a single flight. You can always cancel a flight; there are no emergency takeoffs. You can substitute a crew before a flight with no safety implications. You can substitute a plane with no safety implications. And aviation has the huge advantage of paying customers. If no one wants to fly to Fargo, you just stop going there. A hospital can't just close dialysis because it's unprofitable. If serving an airport requires a night circle to land approach, you don't fly there or you get the FAA to pony up for an ILS. Residencies can't decide to not put in chest tubes at night.

    There are clearly many challenges that professional pilots face, but the duty hour issues in aviation really have no bearing on medicine. Totally different ballgame.

    Pilot Doc, MD, CFI
     
  19. CambieMD

    CambieMD cambiemd
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    Physicians get better by performing procedures and seeing patients. These changes will reduce the amount of face time that trainees have with patients. This will produce weaker doctors. There is no way around it. The concerns revolving around life style and sleep is changing the way that doctors see themselves. They are now shift workers.

    How much will this cost the, "system."

    Will training be lengthened to compensate for the reduced face time.

    Did the document say anything about hand-offs. This is a period where care is often compromised.

    People who applaud the European model don't mention that the training period in Europe is longer.

    Extending residency training will cost residents more. The will have more financial pressure placed on them. This will ultimately hurt the people that it was intended to help.

    Cambie
     
  20. BMW19

    BMW19 Senior Member
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    I wonder how this will affect AOA approved residencies since they don't have to follow the ACGME rules. Although is seems that they did follow the 80 hour work week in 2003, was that a federal mandate as opposed to just ACGME?


     

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