ACGME Duty Hours violation?

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xaelia

xaelia

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I have a scenario on my upcoming rotation where the program is counting my post-call days as my days off. We're essentially Q3, so they're claiming I basically have 7 days off during the rotation, why am I complaining? The key to their argument seems to be that the call shift is _exactly_ 24 hours - and the following 24 hours before I have to come back the next morning at 6am meets the definition of the 1 day off in 7.

This can't possibly be kosher, right? I'll spend part of every single calendar day next month at the hospital, otherwise.

God I hate off-service chiefs.
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Unfortunately, the ACGME has not come down hard on this type of behavior and essentially says, "its up to the program as to how they define it." From the ACGME FAQ:

"Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities."
Question: The common duty hour standards state that residents must be provided with 1 day in 7 free from all responsibilities, with one day defined as one continuous 24-hour period. How should programs interpret this standard if the "day off" occurs after the resident's on-call day?​

Answer: The common duty hour standards call for a 24-hour day off. Many RCs have recommended that this day off should ideally be a "calendar day," e.g., the resident wakes up in his or her home and has a whole day available. Others have noted that it is not permissible to have the day off routinely scheduled on a resident's post-call day.​

Having the day off always occur on a non-post-call day may be difficult to implement in some small programs, but the requirement for a rest period after in-house call would take part of a postcall day, making it less than a full 24 hours free of program duties. Because call from home does not require a rest period, the day after a pager call may be considered 24 hours off. Other RCs have not been as explicit, but would likely not consider it appropriate to have the residents' day off regularly scheduled on their post-call day.​
 
Technically this is probably not kosher, but I suggest you just suck it up and not complain and just do it. Remember, they can always hurt you more (if you are house staff) and the sure thing about intern year is it will end 🙂

The only possible way I would ever report this (and then only MAYBE and if you have a lot of balls) is if you are a prelim intern and planning to move on soon and don't care who gets p.o.'ed at you.
 
Winged Scapula said:
Unfortunately, the ACGME has not come down hard on this type of behavior and essentially says, "its up to the program as to how they define it." From the ACGME FAQ:

“Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities.”
Question: The common duty hour standards state that residents must be provided with 1 day in 7 free from all responsibilities, with one day defined as one continuous 24-hour period. How should programs interpret this standard if the “day off” occurs after the resident’s on-call day?​

Answer: The common duty hour standards call for a 24-hour day off. Many RCs have recommended that this day off should ideally be a “calendar day,” e.g., the resident wakes up in his or her home and has a whole day available. Others have noted that it is not permissible to have the day off routinely scheduled on a resident’s post-call day.​


Having the day off always occur on a non-post-call day may be difficult to implement in some small programs, but the requirement for a rest period after in-house call would take part of a postcall day, making it less than a full 24 hours free of program duties. Because call from home does not require a rest period, the day after a pager call may be considered 24 hours off. Other RCs have not been as explicit, but would likely not consider it appropriate to have the residents’ day off regularly scheduled on their post-call day.​


It's actually worse. 1 in 7 days is what the AVERAGE schedule has to show. In other words, my friend has worked 26 days in a row but got the first two and last two days of the month off. This poor bastard has to go in at 5:30am Friday, get's off Sat. morn. around 9am...then GOES BACK IN SAT. NIGHT AT 8pm. Absolutely ridiculous.
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bluealiendoc
I believe that is a violation of the work hours.
That would be a program to avoid, unless you love everything else about it...
 
Yeah, I'm not interested in the specialty involved and I've read the other fields don't have such a silly work schedule. It's a shame that problems like this continue because no one will say anything about it. I've been real disappointed in so many people not having the courage to stand up for what is right. Seniors who give the ole' 'I had to do it' is nonsense. Or, 'I've put in my time so I shouldn't have to work more to help the interns out'. Well, how does a resident of 4 or 5 years sound to an attending of 30 years when he/she says 'I've put in my time'? It's all relative. It is the ACGME making the laws, not the interns and residents. If the ACGME did research that supports working no more than 80hrs and that's the law, then so be it. It is the responsibility of the program to uphold this. What people don't seem to get is that if they really want it changed, then working people over 100hrs/week then essentially forcing them to report 80 is only going to strengthen the data that mistakes occur due to fatigue even from working 80hrs/week. Also, like I mentioned before, the law is supposed to limit interns/residents to 80hrs/WEEK, not 80hrs/week on a monthly average. The only way to really enforce this would be to use time clocks. You can bet your cheeks that if a resident/intern was clocking over 100hrs...payroll would get involved and the problem would be eliminated quickly. It would be nice to see if working 80hrs/week would be overall better for a program. Unfortunately the data is so corrupt due to so many programs violating the 80hr cap. And, having someone do a 24hr shift then turn around and come back that same night is ludicrous.
 
Actually, there are a few misconceptions in your post.

1. The rule is 80 hours on average. Not strictly 80 hours each week.
2. It's a rule, not a law.
3. Since residents are paid on stipend, regardless of how many hours they clock, payroll wouldn't care if they never went home. The only time they *might* care is if they had to pay overtime for anything over 80 hours. And even then, it would be the individual department chairs against whose budgets the overtime was charged that would care, and not really payroll.
4. ACGME's only dog in this fight is to self-govern responsibly enough (in the eyes of the public) to avoid any increase in government regulation and oversight of residency training. If you think there's any warm and fuzzy motive here regarding resident well-being or patient safety, you would be mistaken.
 
Sometimes it is necessary to go the extra mile for the patient, and that includes working over the work hour limits, which were arbitrarily made and in any case sometimes the real world of medicine won't fit into the little boxes we set up. When I was in intern and had been on call x 30 hours and it was noon on a postcall day, but a patient is coding or the patient's elderly mother drove in from 8 hours away and wanted an update on his condition, sometimes I had to suck it up and stay over my work hours.

However, having said that, what you describe is systemic abuse of the work hours regulations. These aren't a "law" as you stated, but are duty hour guidelines that the ACGME is supposed to be trying to enforce.

It's is easy for you to say "Stand up for your beliefs", but wait until you are house staff. If one want to become a practicing physician, one has to finish a residency. See multiple threads on this forum and others ("drowning" on anesthesiology forum, etc.) to see what happens when a resident falls afoul of the program leadership. Those who complain tend not to get good evaluations and not to last very long in their residency program. If you think the problem is so bad at your institution, why don't YOU report the problem to the ACGME.
 
I think a 24-hour period at home can count as a day off, even if it's not a typical "day."

For example, say you're on in-house call Monday night, leave post-call on Tuesday morning at 7 am. If you return to the hospital on Wednesday morning at 7 am, some programs may call that a "day off."
 
Blade28 said:
I think a 24-hour period at home can count as a day off, even if it's not a typical "day."

For example, say you're on in-house call Monday night, leave post-call on Tuesday morning at 7 am. If you return to the hospital on Wednesday morning at 7 am, some programs may call that a "day off."
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Your right -it does count. As I noted above, ACGME does not have any regulations regarding this issue. They merely note that some residency committees see a post-call day as a legit day off and others do not. Thus, your program can do whatever they want because the duty hours language does not address this issue.

Here is the link to the hours statement: http://www.acgme.org/acWebsite/dutyHours/dh_Lang703.pdf
 
xanthines said:
Perhaps he or she is in NY where it actually is a law? I believe it is enforced through the health dept and punishment is $2000. Not much of a law, if you ask me, though...

-X
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The OP lists his/her location as Greenville, which is probably a bit south of NY. But most residents in NY will tell you that having a law and enforcing it are two radically different things.
 
I'm not in NY and I totally agree! 🙂

I believe that bluealiendoctor was the one throwing the term "law" around, not the OP. I was referring to his/her posts. Sorry for the confusion!

-X

Winged Scapula said:
The OP lists his/her location as Greenville, which is probably a bit south of NY. But most residents in NY will tell you that having a law and enforcing it are two radically different things.
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Winged Scapula said:
The OP lists his/her location as Greenville, which is probably a bit south of NY. But most residents in NY will tell you that having a law and enforcing it are two radically different things.
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There are 47 states with a "Greenville" (including NY).

When I was at a city hospital in NYC (HHC), I documented all my work hours truthfully, even when I was over. I thought that was better than getting arrested.
 
Entertaining if-it-weren't-my-life update:
"It says I'm off today on my schedule."
"Right, you're off after rounds post-call."
"If I stay for rounds, then it's not 24 hours off consecutively and it's not a day off."
"Well, that's just how we've always done it. You're off post-call."
"You can't stay for rounds post-call and be off at the same time. I don't get any other days 'off' this month besides these post-call days."
"Well, you have all those vacation days."
"Those don't count."
"They do in my book."

Sigh.
 
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xaelia said:
"Well, you have all those vacation days."
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I feel for you. This is specifically forbidden by the ACGME. Vacation time must be excluded from calculations of work hours and days off. If you take a week vacation, they still must give you 3 days off for the remaining 21 days.

Ed
 
Just FYI, it IS 24 hours consec. off in 7. 80 hours is an average over the rotation.

These are not laws, in general, however, the ACGME is significantly stepping up ramifications if programs are found to be abusing this. (residents fill out anony. surveys that are required... the consequenses for NOT filling them out, as has been past history, is going to have increasing consequenses as well)
 
My wife's program has this set up as well, whereby the only day off is a post-call day. If it doesn't violate the letter of the ACGME rule, then it at least violates the spirit of it. Besides, I can tell you that in practice the post-call day NEVER results in a continuous 24-hour period away from duties, so in reality it even violates the letter of the rule.

Also, the self-reporting system the ACGME relies on is a complete joke. Do they really expect anyone to turn in their own program? If there's a bigger conflict of interests I'd like to hear it. Anyone that does turn in their own program is probably so bitter that the residency already has a ready-made defense. Again, from my wife's program, those that did respond to the survey honestly were chastised by the residency leadership, as if it was their fault that the program is messed up.
 
The 80 hour workweek rule/guideline has decreased the work hours, but in general "strict enforcement" is a joke.
It seems there are still many surgery and OB/Gyn programs that are doing what is described above. And the way it works, the 24 hours off is never really a full 24 hours off. If they wanted to do that, the intern would have to get to go home before rounds in most all cases...and we all know that ain't gonna happen.

Agree that most residents won't, and really can't, report their own programs. In theory one can file an anonymous complaint, but in reality it's probably pretty easy for a program to figure out who complained, particularly in a small to medium sized OB/Gyn or surgery program. Usually the intern/resident fears personal repercussions, as well as feeling guilty about not wanting to hurt his/her own residency program. The only people I've know of or heard of reporting things to ACGME were either prelim interns who knew they were leaving at the end of the year, or "off service" interns. I'm sure there are exceptions, but that's usually how it is.
 
Those posts are unfortunate truths. The real solution would be for program directors to approach the ACGME and discuss their position with the 'rules'. You mentioned how interns/residents will feel 'guilty' for reporting or 'fear the repercussions' of doing so. Well, I don't see any PD's feeling guilty for violating the rules or worrying about any repercussions of violating the rules. Over-working your interns is no way to maintain a positive and effective crew. I don't think getting home around 9am then not going back until 6am the next day is that bad...however those programs where I have heard of interns working a 24-28hr shift then having to go back the same evening of the day they got home is just plain cruel and unecessary. Also, I don't think having to work over 20 days consecutively with each day being at least 14 hours long is appropriate either. I certainly understand that in medicine we often have to make sacrifices and suck it up. But those should be occurrences that come along, not the norm. People should realize that no one is going to dismiss an entire crew of residents. Perhaps one whistle blower is in jeopardy, but if everyone has a voice..things can get done.
 
Bluealiendoc
you make some excellent points
including the one about the programs needing to discuss/bargain with ACGME perhaps. I also agree that the occasional "being over" by an hour or 1/2 hour isn't that big a deal. I personally didn't care when I had to work 30.5 hours...it's more of a quality of work/life issue. I do think that 20 days in a row of working is too much...have done it when I was a med student and it's not fun or very educational either.

However, I think you are missing the point about programs not being able to "fire all the residents". In fact, many surgical programs probably could find an unlimited supply of IMG's beating down the door to get in to a surgical prelim year...or at least willing to take one, even if working conditions aren't that great. Also, when you are an intern or resident you probably won't be wanting to offer yourself up as the sacrificial lamb to try to get the work hours enforced...at least not if you have any sense of self-preservation whatsoever.
 
We might actually get the schedule addressed by our PD - obviously, with only 24+ calls and 12 hour days, our daily average work is >12 hours, and without days off, our duty hours are >80 throughout the month. Woo, maybe I'll get one day off sprinkled in there!
 
Actually, I think you missed the point. Maybe a program can fire all of its residents...this wouldn't be the best thing for the program however. It would be tough to explain to the ACGME or anyone else for that matter why all of their residents were canned. Again, if all of these residents stated how they were fired for trying to uphold the rules set forth by ACGME, more trouble would arise for the program. Sure the program can come up with all kinds of reasons why someone was fired, but to try and say that all the residents and interns were deficient only makes them look more suspicious. The whole point to all of this is that the current system is faulty. Look at the Lehman Bros. situation.....for years people knew they were doing something wrong...nobody said a word and now it's come to bite them all in the keester. People constantly turn their heads and ignore the corruption. Wanting to improve on something shouldn't be considered rebellious or ignorant. It is this attitude that so many medical students/interns/residents...all the way up have developed due to the beat down process of the medical education. Keep you head down and follow the line.............bahhh, bahhh.
 
I actually think that maybe you missed my point.

I don't disagree with you in a THEORETICAL sense, just in a practical sense.

You aren't going to get a whole group of residents to threaten to quit over work hours, because they need to finish a residency to practice medicine. It sounds nice to ride out on your white horse tilting at windmills and mow down all the injustice in the world, including in your residency. However, when you are a resident/fellow, your perspective may change.

However, I agree that perhaps a united group of interns/residents might be able to bargain to alter the call schedule/work hours, as long as a workable alternative structure can be designed. Usually in these types of situations the core problem is a lack of enough residents to do the work that has to be done, and that isn't easily fixed. When my program had some work hours issues, they really didn't get fixed until the number of interns was increased a couple of years later...POOF...the problem was magically gone.
 
As a resident, there is little to nothing that can be done within your program to fight duty hour abuses if your program director is unsympathetic. Logging duty hour violations will result in pressure to perform more efficiently and to log fewer hours, not changes in the way the schedule is structured. The best way for duty hour abuses to be addressed is by national resident associations to continue to pressure ACGME for some type of oversight and enforcement that does not penalize residents in a program, nor penalizes "whistleblowers".
 
bluealiendoctor said:
Actually, I think you missed the point. Maybe a program can fire all of its residents...this wouldn't be the best thing for the program however. It would be tough to explain to the ACGME or anyone else for that matter why all of their residents were canned. Again, if all of these residents stated how they were fired for trying to uphold the rules set forth by ACGME, more trouble would arise for the program. Sure the program can come up with all kinds of reasons why someone was fired, but to try and say that all the residents and interns were deficient only makes them look more suspicious. The whole point to all of this is that the current system is faulty. Look at the Lehman Bros. situation.....for years people knew they were doing something wrong...nobody said a word and now it's come to bite them all in the keester. People constantly turn their heads and ignore the corruption. Wanting to improve on something shouldn't be considered rebellious or ignorant. It is this attitude that so many medical students/interns/residents...all the way up have developed due to the beat down process of the medical education. Keep you head down and follow the line.............bahhh, bahhh.
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Me thinks you overestimate how much ACGME or programs actually care about these things.

The work hour regulations are not heavily enforced by ACGME, ACGME has "outed" more than 1 person who did complain and the measures to enforce the regulations are laughable at best.
 
Winged Scapula said:
Me thinks you overestimate how much ACGME or programs actually care about these things.

The work hour regulations are not heavily enforced by ACGME, ACGME has "outed" more than 1 person who did complain and the measures to enforce the regulations are laughable at best.
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Absolutely. And when it does, there are some programs who will stop at nothing to get even. Bluealien, medicine is a world full of people with fragile egos and great power. This is a very seductive, and in some personalities, dangerous combination.

Winged is right. The only reason work hour rules exist at all is because John Conyers introduced legislation into the House of Representatives in 2001 after national news media began talking about the abuses. He was joined by about 100 co-sponsors. Organized medicine fought this bitterly and the ACGME finally agreed to issue and enforce and report to congress the results work hour rules changes. Conyers, joined by the late Paul Welstone in the Senate, proposed the following rules:

Maximum 80 hours per week. No exceptions. No averaging.
Maximum time on duty 24 hours. No exceptions.
Minimum of 1 in 7 days off, I don't recall averaging or not.

The ACGME began issuing these "surveys" to accrue "data" which are well known to say exactly what they need to say to appease Congress. Congress was appeased and everyone lost interest. Harvard published a prospective well designed study to see if the hours reported were true. The authors concluded that fraud was rampant, and not in the residents' favor. Some has criticized this study as "old" and not reflective of the new era, but I suspect based on mainly this forum and my own institution, that this is unchanged.

Make no mistake, programs that are the worst abusers will continue to abuse, then can at the very least make your life more miserable than you can imagine, and can potentially destroy your fledgling career. While I feel this is unamerican and should not be tolerated, it is what it is.

Perhaps we should all consider going to the last bastion of free enterprise left in the world: Russia.
 
3dtp said:
medicine is a world full of people with fragile egos and great power.
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Oh this is so right on the money.

What the future will hold, noone knows. Obviously the ACGME is in bed with residency programs. The question is when will anyone notice. If the current rules were actually followed, everyone could be made happy. Of course programs blatantly ignore the rules and the ACGME turns a blind eye. Eventually, the government will get interested again and perhaps OHSA will get involved.

Ed
 
Damn good responses...all of ya. Yeah, I know it is the way it is. The paradox will come if another study is done on medical errors vs. fatigue when they find just as many errors yet a log book showing that the interns/residents were only working a max. of 80hrs/week. It will either become obvious that lies are being told or that 80hrs is too much. But as one of you said I don't think the ACGME really cares that much. Well, I guess that's just the way it's gonna be for awhile...if not forever. Thank you all for your input.
 
bluealiendoctor said:
::average 1 day off, 2 days off, 4 weeks, 2 days off scenario
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According to my program director, that would work since it's 48 continuous hours in a 2 week span, just with those 48 hours coming at the beginning and end respectively. The only catch I can see is that you don't have any time off during the middle two weeks.

The intern schedule for surgery months is, for the most part, 4-5 days on, 36 hours off, 3-4 nights, 36 hours, repeat. So we get the balance of the first night shift and last night shift plus a day when switching to/from night float.
 
Samoa said:
Actually, there are a few misconceptions in your post.

1. The rule is 80 hours on average. Not strictly 80 hours each week.
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IIRC, it's 80 hours average over a running 4 week period. So, technically speaking and assuming no other rules restriction they can run you 13 straight 24 hour shifts, provided you had 2 weeks straight off immediately before AND after that 2 week run so that each 4 week average that includes those two shifts won't average to over 80 hours.
 
Siggy said:
IIRC, it's 80 hours average over a running 4 week period. So, technically speaking and assuming no other rules restriction they can run you 13 straight 24 hour shifts, provided you had 2 weeks straight off immediately before AND after that 2 week run so that each 4 week average that includes those two shifts won't average to over 80 hours.
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FYI: you're responding to a 6 year old thread.
 
Winged Scapula said:
FYI: you're responding to a 6 year old thread.
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DAMN IT... I'm trying to figure out now how this thread got opened in my browser... was it linked in the other bumped hours thread?
 
Winged Scapula said:
FYI: you're responding to a 6 year old thread.
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Well the OP now lists their status as an attending, so apparently things worked out. 🙂

Lest anyone else IS still following these issues: in general, you want to pick your battles. Whistle blowing is not something you want to do lightly and if a Program is more or less within the letter of the rules, albeit imperfectly, I probably would keep my head down and muscle through. If you are supposed to get 24 hours off, but if once in a while it's really 23 I'm not sure many of us would consider the violation alone something to make much noise about.
 
Law2Doc said:
Well the OP now lists their status as an attending, so apparently things worked out. 🙂

Lest anyone else IS still following these issues: in general, you want to pick your battles. Whistle blowing is not something you want to do lightly and if a Program is more or less within the letter of the rules, albeit imperfectly, I probably would keep my head down and muscle through. If you are supposed to get 24 hours off, but if once in a while it's really 23 I'm not sure many of us would consider the violation alone something to make much noise about.
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Yeah I would just lie about my actual duty hours (intern year). The first time I was honest and spent my one day off meeting with the PD and chief about why I violated duty hours. During our discussion, I told them by having this meeting, I'm violating duty hours. Glad those days are long gone!
 
The 24hr counts as a day off rule is a pain, but perfectly legitimate. I had a friend from med school who did a surgery program where she would work 6am-6pm x 5 days, have 24 hours off, work 6pm-6am x 5 days, have 24 hours off, work 6am-6pm, etc. For months at a time. Follows the letter of the law, but if you put me on that schedule I'd shoot myself within the month.
 
Raryn said:
The 24hr counts as a day off rule is a pain, but perfectly legitimate. I had a friend from med school who did a surgery program where she would work 6am-6pm x 5 days, have 24 hours off, work 6pm-6am x 5 days, have 24 hours off, work 6am-6pm, etc. For months at a time. Follows the letter of the law, but if you put me on that schedule I'd shoot myself within the month.
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Did the day shift include prerounding? Sure, signout occurs at 630 and 1800 (night float->primary and primary ->night float), but that doesn't include the time required for pre-rounding.
 
Siggy said:
Did the day shift include prerounding? Sure, signout occurs at 630 and 1800 (night float->primary and primary ->night float), but that doesn't include the time required for pre-rounding.
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If you log a 24 hour break from the hospital, it's a day off. I mean sure, you could log your hours accurately and then your program would be violating... but if your program is malignant enough to give you a schedule like that, how do you think they'll respond to your accurate log?
 
Raryn said:
If you log a 24 hour break from the hospital, it's a day off. I mean sure, you could log your hours accurately and then your program would be violating... but if your program is malignant enough to give you a schedule like that, how do you think they'll respond to your accurate log?
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Squeaky wheel gets replaced... however it suddenly stops becoming "perfectly legitimate" and moves into the "technically correct, but practically wrong" territory.
 
Raryn said:
The 24hr counts as a day off rule is a pain, but perfectly legitimate. I had a friend from med school who did a surgery program where she would work 6am-6pm x 5 days, have 24 hours off, work 6pm-6am x 5 days, have 24 hours off, work 6am-6pm, etc. For months at a time. Follows the letter of the law, but if you put me on that schedule I'd shoot myself within the month.
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Back in the day, that would be a wimpy schedule for a internal medicine resident, and would be an absolute vacation compared to the typical surgery schedule
 
michaelrack said:
Back in the day, that would be a wimpy schedule for a internal medicine resident, and would be an absolute vacation compared to the typical surgery schedule
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Back in the day you never had night float weeks. I'd rather have old-school q3 call with post call days rather than that schedule.
 
Winged Scapula said:
"Old school" didn't have post call days. You stayed post call just like everyone else until the end of the day (whenever that was).
Click to expand...

True. I think he means the interval scheme a lot if us lived through, though.
Strange as it sounds, the 30ish hour shifts with post call days and an 80ish hour average week that some of us endured turns out to be a lot more desirable if not humane than the current set ups. Night float is only a good idea on paper. Working at night 6 out if 7 days and trying to switch back is brutal. And 30 hour max shifts are much better than 24 because you max out your 80 hours in fewer shifts with fewer sign outs. I feel for the current interns.
 
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