New ACGME guidelines - any insight?

[Paul Simon]

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The new ACGME guidelines passed yesterday. PGY-1 residents will be limited to 16 hour shifts, starting July 2011.

Are there any faculty or current housestaff that can provide insight into how this will be accomplished and/or how this will affect the training of those of us entering the match this year? You don't have to identify your programs, but a general idea of what your program is planning to do would be nice.

Thanks.

 

[edmadison]

The new ACGME guidelines passed yesterday. PGY-1 residents will be limited to 16 hour shifts, starting July 2011.

Are there any faculty or current housestaff that can provide insight into how this will be accomplished and/or how this will affect the training of those of us entering the match this year? You don't have to identify your programs, but a general idea of what your program is planning to do would be nice.

Thanks.

Big programs should have no trouble. I suspect that most will go to an intern night float system. Smaller programs, on the other hand will have much more difficulty. I don't think I'd want to be a PGY2 or PGY3 in a small program during this time of transition, because they'll be asked to pick up the slack (e.g. take call without and intern -- yuck).

Ed

 

[Sweet Tea]

We went to an intern and senior night float system this year. I think it's working out great from a senior perspective. I'm just coming off a month as ward senior and I had one PGY-2 on my team who had done the wards with call as an intern, and then this month as a return with night float. She seemed to like the night float system, but didn't like that it didn't give her the opportunity to talk about her decisions and the events of the night on rounds. And while there's no call, the interns are working more days as more people have to work on the weekends. They still get at least 1 day off per week, but the golden weekend is gone.

 

[heartpeds]

The new ACGME guidelines passed yesterday. PGY-1 residents will be limited to 16 hour shifts, starting July 2011.

Are there any faculty or current housestaff that can provide insight into how this will be accomplished and/or how this will affect the training of those of us entering the match this year? You don't have to identify your programs, but a general idea of what your program is planning to do would be nice.

Thanks.

Are these guidelines mandatory? I didn't hear anyone mention this today at work. Sounds great to me!!

 

[lockjaw]

We went to an intern and senior night float system this year. I think it's working out great from a senior perspective. I'm just coming off a month as ward senior and I had one PGY-2 on my team who had done the wards with call as an intern, and then this month as a return with night float. She seemed to like the night float system, but didn't like that it didn't give her the opportunity to talk about her decisions and the events of the night on rounds. And while there's no call, the interns are working more days as more people have to work on the weekends. They still get at least 1 day off per week, but the golden weekend is gone.

This is part of what worries me about the new guidelines - interns need to be able to have a life at least once and awhile. Never having a full weekend off to have a social life is not really okay.

 

[TexasRose]

It's interesting what seems to be happening at our program. We used to be very front-loaded. Very few golden weekends during intern year (as in 3 or 4 the entire year!). Now the interns have fewer patients on their case load, upper levels are acting as interns again, and it looks as if the upper level residents will be working harder than the interns once the 16hr rule is in effect. (upper levels are allowed to work 24hrs) I'm sure that's not a big deal to folks who do their entire training that way, but for those who started with the front-loaded system and are now transitioning to the new system, it's pretty painful.

 

[Dr.PPBBB]

Don't forget that the new ACGME rules also allow for 4 additional hours related to patient signout and other activities:

VI.G.4.b).(1) It is essential for patient safety and resident education that effective transitions in care occur. Residents may be allowed to remain on-site in order to accomplish these tasks; however, this period of time must be no longer than an additional four hours.

I'm not clear on whether this applies only to PGY-2 residents and above, or whether interns are included in this rule. But it effectively increases the work hours to 28 for PGY-2 and above, and possibly 20 hrs for PGY-1's.

 

[CrazyPeds527]

From talking to people interpreting the rules, the "+4 rule" only applies to call for PGY-2 and above. The 16hr rule for PGY-1 is going to be a "hard" rule, but as I commented in a previous thread, there is an "out" on this as well

VI.G.4.b).(3) In unusual circumstances, residents, on their own initiative,
may remain beyond their scheduled period of duty to continue to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family.

Then there is some other stuff about documentation of this to PDs, etc.

The discussion about this has been varied. Residents at some instiutions, pediatrics and non-pediatrics, have intimated that PDs and DIOs have been "burying their heads in the sand" hoping that these standards wouldnt be passed. Wake up guys, it happened, and now you have to plan for it.

Institutions who have already begun transition this year, or who have tweaks to make to systems that have been in place for years have a considerable leg up on other places.

Overall, this will make significant changes to "front-heavy" programs that loaded call into intern year with the hopes of making for less heavy 2nd and 3rd years. As to what it means for training length, I don't think this changes the prospect for pediatrics, but in other specialities that are dependent on procedure numbers (surgery or ob/gyn anyone?), it may result in lengthened residencies down the road. Many colleagues in these various surgical residencies have already commented that when they finish residency, some of them feel like they aren't totally ready to be attendings (although I don't know if this feeling existed before duty hours), due to experience or lack there of...

Oh, one more thing - if you are in a small program, good luck...your challenge is immensely greater than those of us in larger programs

 

[Paul Simon]

Thanks for the comments, folks. As long as the 16 hour rule does not interfere with patient care or resident education, I can see the benefits. That being said, I don't think anybody will complain about staying past 16 hours to take care of a critically ill patient. I hope that the transition to these new guidelines will be guided by common sense, wherever I end up.

 

[Bitsy]

Thanks for the comments, folks. As long as the 16 hour rule does not interfere with patient care or resident education, I can see the benefits. That being said, I don't think anybody will complain about staying past 16 hours to take care of a critically ill patient. I hope that the transition to these new guidelines will be guided by common sense, wherever I end up.

I haven't met anybody that's actually involved in residency....aka residents or program directors that are excited or think that these new work hour restrictions will benefit resident education or patient care so that should tell you something. Unfortunately, it's coming regardless of whether we like it or not 🙁

 

[SeminoleFan3]

I haven't met anybody that's actually involved in residency....aka residents or program directors that are excited or think that these new work hour restrictions will benefit resident education or patient care so that should tell you something. Unfortunately, it's coming regardless of whether we like it or not 🙁

People said the same thing when the current regulations went into effect, and I doubt you'll see any current residents clamoring to work 100+ hrs/wk.

 

[MonkeyRalph]

I don't know anyone, interns included, who think this is a good idea. 16 hours is such an arbitrary number. The difference in my mood, thinking, or skills after 16 hours and 24 hours is negligible. Interns have the lightest thinking workload anyways. They do mostly paperwork/notes/orders, which senior residents should be checking anyways.

 

[oldbearprofessor]

People said the same thing when the current regulations went into effect, and I doubt you'll see any current residents clamoring to work 100+ hrs/wk.

Actually, in pediatrics, and this is a pediatric discussion group, there was very little opposition to the implementation of the previous work guidelines. Remember, pediatrics was the field of "Intern Blues" and could be a very long work week. Only a small number of the "old guard" (defined as anyone older than me 😛) in pediatrics was opposed to it. Many programs had actually adopted fairly compliant rules before the new guidelines came into effect. The biggest objection came from those in critical care fields who felt that procedural learning would suffer from the absoluteness of the rules on leaving after 30 hours.

History has I think, shown that concern to be somewhat valid. Procedures are, for better or worse, less emphasized now than they used to be. Work hour rules are one of the reasons, but certainly not the only one. Still, the benefits to having days off, not working 36 straight hours, etc are such that I believe that the overwhelming majority of pediatric attendings support the previous rule changes.

Now, the current changes have nowhere near that support. First, it is far from clear that these changes will really benefit the resident's life. Furthermore, no one can doubt that training in intensive care fields will be decreased. Those who decry increased involvement by advanced practice nurses may see their concerns become more real in this setting. And, as noted, some small programs may close.

Regardless, we in pediatrics will adapt and will almost certainly do it without adding time to the residency. The only hope is that there will be a clear and unbiased look at what the changes have brought in 3-5 years and consideration if they were worth it. If the training remains solid, while improving the lives of the residents and perhaps enhancing the safety of patients, then fine, we'll accept these changes. But, more so even than last time, there is a legitimate concern that the new rules, especially the 16 hour one, are punitive, not supportive, and that the life of residents and patients will markedly get worse as will the training. We'll see if this can be honestly evaluated in a few years.

 

[Bitsy]

People said the same thing when the current regulations went into effect, and I doubt you'll see any current residents clamoring to work 100+ hrs/wk.

Awesome post OBP! SeminoleFan.....If you're a medical student now, how would you be intimately involved with residency when the current (soon to be old) regulations were instituted? Also, I'm confused what you're trying to convey with the statement "I doubt you'll see any residents clamoring to work 100+ hrs/wk." The current work hours limit us to 80 hrs/wk averaged over a month period. Pediatric residency is very busy and you can have some rotations where you're pushing the 80 hour work limit, but I don't think any reasonable program will have you working 100+hrs/wk.

 

[SeminoleFan3]

Awesome post OBP! SeminoleFan.....If you're a medical student now, how would you be intimately involved with residency when the current (soon to be old) regulations were instituted? Also, I'm confused what you're trying to convey with the statement "I doubt you'll see any residents clamoring to work 100+ hrs/wk." The current work hours limit us to 80 hrs/wk averaged over a month period. Pediatric residency is very busy and you can have some rotations where you're pushing the 80 hour work limit, but I don't think any reasonable program will have you working 100+hrs/wk.

I was talking about when the original 80hr work week went into effect. One can easily read accounts and arguments from docs that training would suffer, and as OBP has pointed out, some parts have (procedures). However, that doesn't leave current residents complaining that they're not working more than 80hrs to get that experience.

 

[mytirf]

I have to confuse, that while on one hand the concept of limiting hours to 16 for interns is a good idea, I do think there will be something lost in the training.

I wasn't an intern too long ago, but I do remember that some of my most important (and harrowing) learning experiences, did occur at hour 29 or hour 30. Maybe it was because I was tired, but seeing a patient all the way through the night, getting feedback on management by my attendings and new team was extremely valuable. Some of those experiences have shaped our I practice medicine on a daily basis and they would have not occurred in the night-float 16 hour system.

Furthermore, I do think that interns and pediatric residents as well are getting more and more limited procedural training. While this may not be necessary for every resident, I do think it is important to know how to place an IV in an infant or to intubate a neonate.

Because of the presence of advanced practice nurses and pushing the opportunities to more "senior" residents and fellows. I think some people are only getting experience in procedures by going to under-served communities or even abroad.

So while I believe the change to 16 hours is inevitable, I'm not entirely sure it is best for training of pediatric trainees.

just my 2c

 

[michigangirl]

We have had a night float system in place at Hopkins for over 7 years now. Procedural experience is not decreased because, well, everyone works nights at some point so it all evens out in the end. Anyway, the majority of procedures outside the PICU and NICU occur in the ER which is usually a shift situation. In the PICU, doing a 24 hour shift vs. more spread out shorter shifts does not mean you get more procedures. The key is residents taking the incentive to do procedures-- i.e. not balking at an art stick in the PICU because "i do plenty of those in the NICU"- do the procedures, small or large, and hone your skills as much as possible. You want to intubate more? do an anesthesia elective. You want to do IV lines? (which frankly is the one procedure I think peds residents don't get enough of and NEED to know how to do well)- put in all your own IVs on the floor or ED, or do an anesthesia elective. Take control, initiative. It's all out there.

 

[blanche]

We have had a night float system in place at Hopkins for over 7 years now. Procedural experience is not decreased because, well, everyone works nights at some point so it all evens out in the end. Anyway, the majority of procedures outside the PICU and NICU occur in the ER which is usually a shift situation. In the PICU, doing a 24 hour shift vs. more spread out shorter shifts does not mean you get more procedures. The key is residents taking the incentive to do procedures-- i.e. not balking at an art stick in the PICU because "i do plenty of those in the NICU"- do the procedures, small or large, and hone your skills as much as possible. You want to intubate more? do an anesthesia elective. You want to do IV lines? (which frankly is the one procedure I think peds residents don't get enough of and NEED to know how to do well)- put in all your own IVs on the floor or ED, or do an anesthesia elective. Take control, initiative. It's all out there.

agreed. night float can be a great time to do procedures--you're there, probably better rested than if it was hour #23 of 30. those were my favorite times as a resident. plus, as a night float resident i never felt that i had to grab every opportunity to lie down if the opportunity arose (as i did if i knew i was pulling a 30-hour call, and would have to suffer through ICU rounds in the AM..) echo the sentiments above also on doing procedures as much as you can. if you find a nicu or picu RN who seems cool, ask them if they'd mind if you worked on your skills if an IV falls out. or to show you where they find veins in difficult sticks. you'd be surprised how much better you'll get.

 

[SurfingDoctor]

I am unsure of the 16 hour rule. Granted I didn't train in the days of no work restrictions, but I think 16 hour limits is too extreme. I mean, if the number of total training hours is the exact same or more, then that's great. But I have a feeling that will not be the case and residents won't come close to working 80 hours per week. While I understand the complaints of working for little pay and not having a time to take care of oneself, residency is a limited amount of time during which one needs to learn all they can to take care of children on their own, efficiently and safely. That means seeing and doing as much as possible in the time available. I don't know all the specifics of the ACGME regulations, but 16 shifts and 4 hour signouts don't seem like they are doing the residents' education justice.

 

[kappa1]

At my program, our model schedules (which are being tested starting now) actually plan for 14-hour shifts ideally, since it was thought that with multiple sign-outs the 16-hour shifts would still break work hours.