IOM's recent recommendations on residents duty hours....

[halifax]

So my program is for various non educational reasons which I won't elaborate is introducing the new work hour rules which are forecast to come into effect in 2011 starting next week.....including the compulsory 5 hours pager free sleep time from 2200 to 0300 for the intern and 0300 to 0800 for the senior on call during the 30 hour shift.

Am curious to see if any other program has this in place already and how is it working.......its not exactly the flavor of the month in my program right now.....

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[error404]

My program hasn't had to deal with this yet, but how will it affect programs where a team has only one person overnight?

The only place I have overnight 30-hr calls is in the ICU-- and it's either the intern OR the resident, so 5 hours of being off pager just doesn't work.

 

[elwademd]

My program hasn't had to deal with this yet, but how will it affect programs where a team has only one person overnight?

The only place I have overnight 30-hr calls is in the ICU-- and it's either the intern OR the resident, so 5 hours of being off pager just doesn't work.

i said it when i was a med student.. when i was a resident... and now as an attending... attendings need to step up to the plate.

technically, the attending is supposed to be available to his/her residents at all times. yes, we all know that may or may not be true, but that's teh way its supposed to be. and the way that it should be.

 

[surrender903]

i said it when i was a med student.. when i was a resident... and now as an attending... attendings need to step up to the plate.

technically, the attending is supposed to be available to his/her residents at all times. yes, we all know that may or may not be true, but that's teh way its supposed to be. and the way that it should be.

But but but OBAMACARE!!!!!

 

[NotAProgDirector]

Remember that the IOM only makes recommendations. It's incredibly unlikely that the ACGME will follow those recommendations blindly. The ACGME is currently looking at it's duty hour rules, planned to be updated in July 2010 (I believe), so I expect we will be hearing from them shortly.

Word on the street is that there is universal agreement that:

1. The 80 hour limit will remain unchanged, averaged over 4 weeks.
2. Patient safety is first priority
3. Supervision standards must be more explicit
4. First year house officer needs differ from SAR’s. Hence, there may be tighter rules for PGY-1's and more flexible rules for more senior residents.
5. Some form of flexibility (level of training, specialty)

There was Evolving consensus on:
1. Nights of consecutive night float (Sounds like 5 will be the number, unlike the IOM's suggestion of 4)
2. Duty hour rules means that the learning environment has changed, impact everything

There remained continued dialog on:
1. 16-18 hour data vs continuity and increased handoffs
2. Naps, sleep, duration, individual (resident) variation
3. Interval of call (q3 vs q4 averaged)
4. Minimum interval between episodes of duty (level specific)
5. Degree of flexibility feasible
6. All moonlighting counted

So, jumping to follow the IOM recommendations will probably make an institution "ahead of the curve", as I expect the actual "curve" will be less than the IOM suggested.

 

[maxheadroom]

While aProgDirector certainly has a closer bead on these issues than I do, from my previous involvement in GME stuff (up until last summer) I've heard/read several things.

1. The IOM's recommendations are never ignored. While their recommendations might not be incorporated to the letter of their previous documents, the ACGME will put the majority of their recommendations into practice. It won't be immediate, but it will happen.

2. Smart programs (like the OP's) will start to proactively come up with solutions to some of the more burdensome rules. Theirs' is a pretty smart approach. It will be a pain, but it's the best that I've seen (and I've seen several).

3. The old guys all sit back and say, "Attendings are on call for their patients ALL of the time." Sure, that's true, but how many attendings take call for an ICU full of sick patients all night, every night? How many attendings spend multiple nights late at the hospital? How many attendings spend a substantial portion of every weekend at the hospital? If they're honest, the answer is "not many." RESIDENCY NEEDS TO BE ABOUT EDUCATION.

 

[Bobblehead]

3. The old guys all sit back and say, "Attendings are on call for their patients ALL of the time." Sure, that's true, but how many attendings take call for an ICU full of sick patients all night, every night? How many attendings spend multiple nights late at the hospital? How many attendings spend a substantial portion of every weekend at the hospital? If they're honest, the answer is "not many." RESIDENCY NEEDS TO BE ABOUT EDUCATION.

Some hospitals have already moved towards 24/7 critical care "attending" level coverage. This was more for the Leapfrog recommendations than ACGME work hours restrictions though. It usually involves some type of rotating faculty and/or senior fellow (cardiology/pulmonary) in-house coverage. The models vary on whether this is voluntary with additional pay or part of the fellow/faculty contract (but often still with additional pay). In a teaching institution that person probably still isn't first call for a 500mL saline bolus but is available when things escalate.

One interesting perspective is that more physicians will enter the workforce following a residency with work hour restrictions to discover that once they're done, there are no more work hour restrictions. If the most expedient way of spreading the work around is to simply require attendings, as part of their hospital privileges, to work more, how will this affect physician retention?

If the workload is the same everywhere you can't exactly leave one hospital for another. But if there are "better" options available across town perhaps that would prompt some physicians to migrate to these institutions. Will family/social commitments keep enough people stationary to permit hospitals to enforce these types of increasing requirements? After all, theoretically physicians are fairly mobile once they're done with training. But if there's no "better" place to migrate to, then you've essentially got a captive audience.

 

[Winged Scapula]

Some hospitals have already moved towards 24/7 critical care "attending" level coverage. This was more for the Leapfrog recommendations than ACGME work hours restrictions though. It usually involves some type of rotating faculty and/or senior fellow (cardiology/pulmonary) in-house coverage. The models vary on whether this is voluntary with additional pay or part of the fellow/faculty contract (but often still with additional pay). In a teaching institution that person probably still isn't first call for a 500mL saline bolus but is available when things escalate.

One interesting perspective is that more physicians will enter the workforce following a residency with work hour restrictions to discover that once they're done, there are no more work hour restrictions. If the most expedient way of spreading the work around is to simply require attendings, as part of their hospital privileges, to work more, how will this affect physician retention?

If the workload is the same everywhere you can't exactly leave one hospital for another. But if there are "better" options available across town perhaps that would prompt some physicians to migrate to these institutions. Will family/social commitments keep enough people stationary to permit hospitals to enforce these types of increasing requirements? After all, theoretically physicians are fairly mobile once they're done with training. But if there's no "better" place to migrate to, then you've essentially got a captive audience.

Perhaps in small towns but in larger cities, there are multiple hospitals. This can be a marketing tool for them to get surgeons and other physicians to take privileges at their hospital (ie, if they require less in house call than hospital B across town, for example).

 

[halifax]

Guess our program would be among the first to try this - lets see how it rolls...not the most popular of proposals among my co residents right now....

 

[Bobblehead]

Perhaps in small towns but in larger cities, there are multiple hospitals. This can be a marketing tool for them to get surgeons and other physicians to take privileges at their hospital (ie, if they require less in house call than hospital B across town, for example).

And I think this is the key issue. Unless all of the hospitals in a geographic area collude in some way to force in house call in a similar fashion, there will always be a "grass is greener" institution to move on to. That will keep the rest of the institutions in check with respect to overall physician workload.

 

[doctorFred]

not the most popular of proposals among my co residents right now....

i'm consistently baffled by this viewpoint, whenever i see it espoused in response to the recent IOM report. although i'm sure it will introduce a host of inconveniences to individual residents, i'd have to believe that the majority of the burden will fall on attendings, residency programs, and institutions at large. i would think that from a resident standpoint, it's net benefit. of course, i'm only a MSIV, so i can't speak from a position of authority just yet.. but i can tell you that on a recent 28 hour call, i would have been significantly more miserable during the last set of morning rounds if i hadn't gotten the pittance of sleep (2 hours) that i had.

 

[Coastie]

You think the residents are actually following the 5 hour naptime?

Don't you think programs will pressure residents to keep that pager on?

It would be tough to be the first set of residents who have to "live" by the rules. Do you think that the 80 hour rule is actually enforced alot of places? When I was in internship, the program ripped up our time sheets in front of us and made us sign 80 hour sheets.

Thankfully, my residency isn't like that.

i'm consistently baffled by this viewpoint, whenever i see it espoused in response to the recent IOM report. although i'm sure it will introduce a host of inconveniences to individual residents, i'd have to believe that the majority of the burden will fall on attendings, residency programs, and institutions at large. i would think that from a resident standpoint, it's net benefit. of course, i'm only a MSIV, so i can't speak from a position of authority just yet.. but i can tell you that on a recent 28 hour call, i would have been significantly more miserable during the last set of morning rounds if i hadn't gotten the pittance of sleep (2 hours) that i had.

 

[doctorFred]

You think the residents are actually following the 5 hour naptime?

Don't you think programs will pressure residents to keep that pager on?

It would be tough to be the first set of residents who have to "live" by the rules. Do you think that the 80 hour rule is actually enforced alot of places? When I was in internship, the program ripped up our time sheets in front of us and made us sign 80 hour sheets.

Thankfully, my residency isn't like that.

i'm not sure what your point is. if that already goes on with the current work hour guidelines, more restrictions on resident duties will make it even more difficult for programs to get away with that sort of thing.

 

[Winged Scapula]

i'm not sure what your point is. if that already goes on with the current work hour guidelines, more restrictions on resident duties will make it even more difficult for programs to get away with that sort of thing.

His point is, if I may, is that if programs can't or won't make it work on 80 hrs, what makes you think they can or will on 56 hrs a week? The ACGME are hardly jackboots when it comes to enforcing these things.

 

[Winged Scapula]

i'm consistently baffled by this viewpoint, whenever i see it espoused in response to the recent IOM report. although i'm sure it will introduce a host of inconveniences to individual residents, i'd have to believe that the majority of the burden will fall on attendings, residency programs, and institutions at large. i would think that from a resident standpoint, it's net benefit. of course, i'm only a MSIV, so i can't speak from a position of authority just yet.. but i can tell you that on a recent 28 hour call, i would have been significantly more miserable during the last set of morning rounds if i hadn't gotten the pittance of sleep (2 hours) that i had.

As a resident you realize there is a finite time to learn the knowledge and skill expected to function as an independent physician. A reduction in work hours does not necessarily translate into more learning and less scut.

Where the line exists between work hours and learning without extending training is an unknown. There is anecdotal evidence from graduating surgical residents that they feel undertrained in the 80 hour module when they get out into practice. This may not be true for everyone, every specialty and every program, but its a pretty scary feeling to see residency fly by and realize that you only have a little time left, and a lot of work to do.

 

[NotAProgDirector]

i'm consistently baffled by this viewpoint, whenever i see it espoused in response to the recent IOM report. although i'm sure it will introduce a host of inconveniences to individual residents, i'd have to believe that the majority of the burden will fall on attendings, residency programs, and institutions at large. i would think that from a resident standpoint, it's net benefit. of course, i'm only a MSIV, so i can't speak from a position of authority just yet.. but i can tell you that on a recent 28 hour call, i would have been significantly more miserable during the last set of morning rounds if i hadn't gotten the pittance of sleep (2 hours) that i had.

In my own (and many other) IM programs, I have busy months (like ICU and wards) and non-busy months (like electives). One possible side effect of instituting very restrictive duty hour rules is that I'll take a bunch of work from the busy months, and move it to the non busy months. Orphan calls, night floats, weekend coverage schemes, etc. Some people might like that -- evening things out somewhat. Others would rather have a busy/crazy month, and then have some "normal" life months.

Bottom line is that the work might not be shifted to faculty, but simply shifted in the schedule to other interns and residents.

 

[Tone2002]

In my own (and many other) IM programs, I have busy months (like ICU and wards) and non-busy months (like electives). One possible side effect of instituting very restrictive duty hour rules is that I'll take a bunch of work from the busy months, and move it to the non busy months. Orphan calls, night floats, weekend coverage schemes, etc. Some people might like that -- evening things out somewhat. Others would rather have a busy/crazy month, and then have some "normal" life months.

Bottom line is that the work might not be shifted to faculty, but simply shifted in the schedule to other interns and residents.

This statement here is exactly Coastie's point.

 

[doctorFred]

His point is, if I may, is that if programs can't or won't make it work on 80 hrs, what makes you think they can or will on 56 hrs a week? The ACGME are hardly jackboots when it comes to enforcing these things.

but as i pointed out, further work hour cuts will make it that much more difficult to egregiously fudge the numbers. and i know that you're hard pressed to find much enforcement, but i think there have been several notable cases each year since 2003 of residents exposing blatant violations. that sort of whistleblowing would likely increase with increasing reforms.

on a personal note, i'd rather have the burden shifted to "easier" months than want to blow my brains out during icu rotations (and possibly be responsible for sub-par care.)

 

[Ashers]

but as i pointed out, further work hour cuts will make it that much more difficult to egregiously fudge the numbers. and i know that you're hard pressed to find much enforcement, but i think there have been several notable cases each year since 2003 of residents exposing blatant violations. that sort of whistleblowing would likely increase with increasing reforms.

on a personal note, i'd rather have the burden shifted to "easier" months than want to blow my brains out during icu rotations (and possibly be responsible for sub-par care.)

As a med student I leaned towards that too, until I actually lived it. In our electives, as interns, we do have to spend 1 weekend a month coming in and helping out with rounding. I resent those days so much. It takes away from my "normal" life because usually it's after a month of q4 call. I'd rather be on, and get the hard stuff out of the way, then have my deserved time off.

As for my intern year... there are still work hour violations. The program tells us to be honest with our time sheets, and when they find issues they work to resolve it... some people have efficiency issues, and for some of our teams, it's so busy that we don't always violate the 30h rule, but we come in earlier than the latest we're supposed to come in (the chiefs assume everyone comes in at 7am -- you do that if you have no patients). And we stay late doing admissions. So I've heard that there are now discussions about what to do for this particular team with issues. However, this is a peds program, and people are generally nice and want things to work out well. There hasn't been talk of the new recs yet.

 

[MeredithGreyMD]

Does anyone know what the IOM recommendations are exactly?

 

[gutonc]

Does anyone know what the IOM recommendations are exactly?

Work less...take a nap.

 

[Substance]

Where the line exists between work hours and learning without extending training is an unknown. There is anecdotal evidence from graduating surgical residents that they feel undertrained in the 80 hour module when they get out into practice.

This is interesting. I wonder if the same people who feel undertrained come from programs with a lot of fellows. I know that many of the major programs around my neck of the woods have a ton of clinical fellows, which makes it super hard for a resident to get any operative experience. Of course, once board certified, the resident feels as if he is inadequately trained and thus gets a fellowship to train more, perpetuating the cycle.

Perhaps it is the abundance of clinical fellows that is responsible for less traning time, and not the restrictions on work hours?

 

[Winged Scapula]

This is interesting. I wonder if the same people who feel undertrained come from programs with a lot of fellows. I know that many of the major programs around my neck of the woods have a ton of clinical fellows, which makes it super hard for a resident to get any operative experience. Of course, once board certified, the resident feels as if he is inadequately trained and thus gets a fellowship to train more, perpetuating the cycle.

Perhaps it is the abundance of clinical fellows that is responsible for less traning time, and not the restrictions on work hours?

I doubt it. Fellows were around before the work hour restrictions. It may be a contributing factor - Chiefs and junior residents do less cases if on service with a fellow (as always) and when coupled with fewer hours to actually learn surgical skills, it leads to a sense that you are unprepared when you complete residency.

 

[THP]

on a personal note, i'd rather have the burden shifted to "easier" months than want to blow my brains out during icu rotations (and possibly be responsible for sub-par care.)

We have begun discussing how the new recommendations would work at my residency program. The limit of 4 days of night float would destroy the resident's lives. Currently I get 2 out 4 weekends off entirely in a month. If we had to go to 4 nights of night float no resident would ever get 2 days off in a row. I would much rather have a weekend totally ruined and have another totally off than have all of them suck. If I only get one day off all I can think about is how much it sucks to have to work the next day.

Who is going to cover our laboring patients and do emergency c-sections in the middle of the night when the residents are supposed to be napping?

I would much rather get all the hard stuff at once and then have an easier month.

 

[SocialistMD]

I would much rather get all the hard stuff at once and then have an easier month.

It isn't about you. It is about what these people think is best for patients.

 

[ranmyaku]

Speaking from experience, the 5 hour napping rule may or may not be used for actual napping. I can imagine that if I had a busy day, admitted 5-8 patients, had lectures, M&M, conferences, and other stuff to do during the day, etc. I would be using those 5 hours of 'protected' nap time to do dictations and finish my work.

 

[J ROD]

I dont think the recommendations will work.....period.

 

[Law2Doc]

...I can imagine that if I had a busy day, admitted 5-8 patients, had lectures, M&M, conferences, and other stuff to do during the day, etc. I would be using those 5 hours of 'protected' nap time to do dictations and finish my work.

If you did that and were "caught" your program would be in jeopardy. So this would be discouraged by any program trying to actually stay in compliance. Currently people are doing what you describe "after hours" and at places that don't discourage this, the program is taking a big risk. If hours are again cut and things like nap-time are inserted, people would still be in violation but that doesn't mean that it's necessarily impossible for a program to be in compliance or that it's necessarily a bad idea.

I do, however think that the nap time is silly because it forces places to have more people on call each night (to cover for each other while they nap), whereas if you really wanted well rested residents, the goal should be to have fewer call nights. I see the nap time as simply making folks spend more, not less time in the hospital once you shift naps to on call nights rather than letting people go home to sleep more often. I say make everyone do a ton of night float in a block so there is no call the rest of the year. Since night float may only be a 12 hour shift, folks can get a full "day's" sleep each day and won't ever need a nap.

 

[halifax]

So having experienced the new system for the past 2 weeks..a few updates....

- Interns are loving it as they get to sleep from 2200 to 0300. And most of the nights they receive the sign out from seniors at 0300 and go right back to sleep as mostly all the teams are capped by then.

- Most of our admissions come during this time including all the train wreck transfers and the senior gets them all for himself....needless to say they're not pleased.

- both interns and seniors hate this as it's replaced the night float.

- nurses have given up on this as we carry 4 pagers in total when the other person is sleeping and they just put our telephone orders under some resident's name.

- The Hospitalist's/Nocturnist are unhappy as now they can't give 2 admissions simultaneously to an intern and a resident during night.

My PD for some reason thinks this is going to be the norm in near future and is in no mood to change anything and is sticking to his guns....

And I'm glad this is my last month of adult medicine...unless I get pulled during my back up rotation.......

 

[dpmd]

I come from a small program and I can't come up with a good way this would work for us. Currently we have one intern on a 30 hr call daily, and then we have a night float senior. There is a home call chief, and an attending. The home call chief gets called anytime there is something the in house senior needs help with (varies with patients coming in, and also with the level of experience of the night float-we start night float 6 months into second year), plus anytime something goes to the OR the chief either scrubs the case or covers for the night float so the intern isn't left to run traumas by themselves. The attending gets called if the chief needs help (rare), if trauma patients meeting certain criteria come in (usually consist of a <1 minute phone call saying such and such came in and I am doing XYZ), or if something goes to the OR.
With the nap rule, the night float would have to either run things alone during the intern nap time (since it is a 12 hr shift I hope the night float doesn't have mandated nap time), or someone would have to come in. If the chief did it they would be nowhere near hours compliance (they probably already are not). If the attending did I would expect our elective case schedule to be affected since there are only 4 of them taking call and I can't picture them wanting to come in for five hours every night and operate all day the next day. They could try to hire a PA/NP but there is no money in the budget and it would take a while to get them trained. The only other thing would be to have in addition to regular call, something awful that would be known as nap call where the unlucky resident would get to leave the hospital at sometime during the day only to have to come in from 2200 to 0300 (and work the next day too I suppose). Absurd.

 

[thedrjojo]

As a resident you realize there is a finite time to learn the knowledge and skill expected to function as an independent physician. A reduction in work hours does not necessarily translate into more learning and less scut.

Where the line exists between work hours and learning without extending training is an unknown. There is anecdotal evidence from graduating surgical residents that they feel undertrained in the 80 hour module when they get out into practice. This may not be true for everyone, every specialty and every program, but its a pretty scary feeling to see residency fly by and realize that you only have a little time left, and a lot of work to do.

Is it the 80 hour module, or is it the shifting away from Autonomy and rules requiring attendings to be present and scrubbed before a case can even start that is making residents feel unprepared? If you never get to operate on your own, how can you feel comfortable entering the world and doing it? You can't go from total hand holding to total freedom... they need to fix that problem and I think 80 hours doesn't have anything to do with it. Another issue could be using physician extenders for more mundane type tasks, that keep residents busy from studying or, in surgical specialties, from getting to the OR.

 

[Pilot Doc]

Is it the 80 hour module, or is it the shifting away from Autonomy and rules requiring attendings to be present and scrubbed before a case can even start that is making residents feel unprepared?

80 hours has its own issues, but the de-autonomizing started before that and was largely a function of tighter enforcement of medicare billing regulations. The need for an attending to be physically present for the "critical" portion of the case has resulted in a lot more attending scrub time.