New ACGME letter on Revised Standards

[Ronin2258]

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24+4 of tidy up time? That basically means call went from 30 to 28 hours total in hospital, if my reading is correct. Barring something drastic (i.e. a emergent case that would tie up the resident with one patient.) I know NY has been at 27 hours of call for a while.

Also, unless I missed something, there is still no protection for whistle blowers.

16 hours for interns. Does that mean the beatings are delayed until PGY-2? When I entered internship, I consigned myself to being beaten.

If manning is an issue, I can see a few more preliminary slots open up just for intern coverage. But then, that means we are going to have a bunch of people with nowhere to go for PGY-2+.

From what I have seen on the board, It appears that a lot of programs are getting dinked on the 10 hour between shifts. Can someone check me on that?

 

[Johnjonny21]

the supervision rules are awful. every pgy1 needs to be supervised by attending at night. the attendings will be pissed as hell to have to be in the hospital at night and the interns will have no autonomy. basically scut monkeys. if anything, having a pgy1 in the hospital at night will be a total negative. instead just have the pgy2 take care of all patient care to avoid requiring attending coverage

 

[VA Hopeful Dr]

the supervision rules are awful. every pgy1 needs to be supervised by attending at night. the attendings will be pissed as hell to have to be in the hospital at night and the interns will have no autonomy. basically scut monkeys. if anything, having a pgy1 in the hospital at night will be a total negative. instead just have the pgy2 take care of all patient care to avoid requiring attending coverage

"In particular, during PGY-1, residents must be supervised either directly or indirectly, with direct supervision immediately available."

"Indirect Supervision🙁1) with direct supervision immediately available – The supervising physician is physically within the confines of the site of patient care, and is immediately available to provide Direct Supervision."
Supervision may be exercised through a variety of methods. Some activities require the physical presence of the supervising faculty member. For many aspects of patient care, the supervising physician may be a more advanced resident."

I wasn't aware that interns were ever left without an upper level in house.

 

[VA Hopeful Dr]

24+4 of tidy up time? That basically means call went from 30 to 28 hours total in hospital, if my reading is correct. Barring something drastic (i.e. a emergent case that would tie up the resident with one patient.) I know NY has been at 27 hours of call for a while.

Also, unless I missed something, there is still no protection for whistle blowers.

16 hours for interns. Does that mean the beatings are delayed until PGY-2? When I entered internship, I consigned myself to being beaten.

If manning is an issue, I can see a few more preliminary slots open up just for intern coverage. But then, that means we are going to have a bunch of people with nowhere to go for PGY-2+.

From what I have seen on the board, It appears that a lot of programs are getting dinked on the 10 hour between shifts. Can someone check me on that?

It looks like 10 hours is recommended now but only 8 is required.

 

[Ronin2258]

the supervision rules are awful. every pgy1 needs to be supervised by attending at night. the attendings will be pissed as hell to have to be in the hospital at night and the interns will have no autonomy. basically scut monkeys. if anything, having a pgy1 in the hospital at night will be a total negative. instead just have the pgy2 take care of all patient care to avoid requiring attending coverage

Kind of like a fifth year in medical school? That is the last thing most of us wanted when we entered intern year.

I allude training as a doctor as Pinocchio, a magical marionette puppet on strings. Gradually, the strings (representing instructors, interns, whoever is above you,) controlling the limbs (you) are cut. First is the basic science knowledge. Snip. You flex and test the limb moving of your own volition. Then comes the clinical observation as a medical student, getting an idea of how to interact with patients. Snip. More freedom. Then comes intern year, where you start to integrate what you know and what you have seen into the practical. Snip again, a bit more freedom, but someone else pulling the last string supporting you. Finally, residency, where you learn to do what you want to do. The final string goes snip, and congratulations! You are a real live boy! (sorry ladies, going with the classical story.)

There has to be a time when you have to see if you can do things on your own. Yes, I have seen interns fall. We all stumble from time to time. But the residents and attendings are there to instruct and guide the actions, pulling you up by that last string. I know I could count on my residents as backup if I needed them. But I had the freedom to use what I learned and did to care for the patients. I had no qualms pulling that last string to bring someone who knew more than me to make sure I was doing it right. Better to be honest and comfortable in your ignorance than kill someone by being cocky. But there must be some room to be able to do things on your own. To me, the handholding is a bit stifling.

I know calls are a necessary evil in intern year. I knew I would be browbeaten on call, and as Stewie from Family Guy said, it would, "shake me like a British nanny." Call is when we learn to put out fires and time organization, with calling the senior we are on with as backup and confirmation that we are doing right. I felt a bit more prepared for PGY-2 call after call as an intern. I can see pushing call up to PGY-2 instead of PGY-1 being deleterious. How long before PGY-2s act like interns on call now? At the next review, does it get pushed up the chain to the PGY-3s?

 

[JackADeli]

The ACGME has posted its new proposed standards to take effect July 2011...

That link should get you to the PDF directly.

 

[Bobblehead]

the supervision rules are awful. every pgy1 needs to be supervised by attending at night. the attendings will be pissed as hell to have to be in the hospital at night and the interns will have no autonomy. basically scut monkeys. if anything, having a pgy1 in the hospital at night will be a total negative. instead just have the pgy2 take care of all patient care to avoid requiring attending coverage

I don't think the supervision requirements specify the type of supervision directly. Note the language: "In particular, during the PGY 1 year, residents must have supervision level 1 or 2a (see below)"

And level 1 or 2a are direct supervision (physically present) or Direct supervision immediately available (in the same facility).

Above they list:

"Faculty functioning as supervising physicians should delegate portions of that care to resident physicians"

"Senior residents or fellows should serve in a supervisory role of junior residents"

In other words a PGY1 can still be supervised overnight by a PGY2 or PGY3 as long as they have an attending available by phone who could in theory be available in person.

 

[rock_climber]

how do you make smooth transitions with a 20 hour shift? i can see 24 hours working (arrive at 6, checkout at 6 the next day) but if you want the intern to cover overnight they can't come in until late in the morning or have just very odd start/stop times.

 

[gutonc]

how do you make smooth transitions with a 20 hour shift? i can see 24 hours working (arrive at 6, checkout at 6 the next day) but if you want the intern to cover overnight they can't come in until late in the morning or have just very odd start/stop times.

It's tough. My residency program implemented (after I left so I can't comment personally on its success, only by what I've heard and seen) a schedule like this in the VA ICU. It was previously a service with 3 - 2 person teams and it was Q3 overnight. Work hour rules were routinely violated, especially when the service was busy. I worked it during the Q3 time and was routinely 100+h. Fortunately, I went to a very resident friendly program and when the PD found out that we were all way over hours, the response was not "change your work hour reports" but was "how do you think we can fix this?".

So they went to staggered shifts and added a "Day Float" upper level resident. It's still Q3 overnight for each 2 person team, but instead of both people coming in at 7a and leaving at 1p the next day, one came in at 7a and left at 7a, the other came in at 3p and left at 3p. The resident and intern would swap who did what on alternating call days. The day float person was 8a-5p M-F. They didn't pre-round on any patients but would be there to round with the attending and other teams on the entire service and would be the one responsible for acute stabilization and supervising or performing procedures as needed. Overall it seems to have worked pretty well and required only one additional resident on the service.

I think it will be difficult, but not impossible, to conform to any new work hour regs. It will require more flexibility and creative thinking on the part of PDs though.

 

[1viking]

These new hours are a major step in the wrong direction. The solution is to not pass the work onto the seniors, but to more effectively orient the interns (like an orientation month).

Making decisions without the aid of an upper level resident is critical to learning. Education just took a major hit.

Small-town ERs are going to hurt dearly by these changes. They survive because of residents willing to moonlight. Moonlighting will be decreased.

These hours are going to increase the number of hand-offs. I can tell you from experience that the major cause of medical errors is hand-off, not fatigue. Increasing hand-offs will only make this worse. And, of course, evidence has shown that reducing the hours to 80 didn't decrease the number of medical errors.

We need to stand up and have this stopped. We owe it to our patients.

 

[PlutoBoy]

We need to stand up and have this stopped. We owe it to our patients.

How much do we "owe" to "our" patients?

 

[1viking]

How much? I took an oath to do no harm. I can't, in good faith, practice effectively with these new guidelines and expect in the future to "do no harm". I owe that much to my patients.

Medicine is like no other field. This isn't just a job, this is a calling, and with that calling comes responsibility.

 

[Neuronix]

And, of course, evidence has shown that reducing the hours to 80 didn't decrease the number of medical errors.

It didn't increase the number of medical errors either.

 

[JackADeli]

How much? I took an oath to do no harm. I can't, in good faith, practice effectively with these new guidelines and expect in the future to "do no harm". I owe that much to my patients...

I guess you must conscientiously object and resign from the medical field.

 

[Moonglow]

I guess you must conscientiously object and resign from the medical field.

Just like a surgeon... wrong, try again. 👎

 

[Winged Scapula]

Just like a surgeon... wrong, try again. 👎

What does his response have to do with being a surgeon?

1viking is stating that he feels that he will be inadequately trained under the new guidelines and is not sure that he can live up to his oath of "do no harm".

JAD responds that if you cannot then I guess you have to quit because you are being asked to take an oath you cannot live up to. I'm not sure he isn't being facetious.

Not sure that's a surgical response (whatever that means) but I realize its popular to ascribe any negative attitudes or behaviors to being a surgeon, or even to blame a resident for the behavior of their program (ie, see response from anesthesia resident to a surgical resident in another thread when the latter notes that when changing rotations you are expected to show up to the new rotation post call and work until 30 hrs. Even when other specialties state they have to do the same.)

 

[1viking]

It didn't increase the number of medical errors either.

So, why change the rules? This will increase the number of handoffs, which are a known problem (reference the NEJM where this discussion is made--known entity of sign out being a significant source of medical errors). If the point is to improve patient care, don't increase one of the main causes of medical errors.

And, yes, I don't feel that adequate training will happen during internship. For instance, laboring patients often take greater than 16 hours to deliver. Continuity of care is lost, which decreases learning.

This is all very political and has less to do with patient care and more to do with the news media and patient perception.

BTW, I'm not a surgeon. I'm a family practice resident.

 

[Neuronix]

So, why change the rules? This will increase the number of handoffs, which are a known problem (reference the NEJM where this discussion is made--known entity of sign out being a significant source of medical errors). If the point is to improve patient care, don't increase one of the main causes of medical errors.

Fatigue is also a known problem that causes patient errors. There is no evidence that the reduction in fatigue is more or less important than the increase in handoffs.

I have inside knowledge about the studies that have been conducted in this area. The institution where I've been a student for seemingly ever now (since before the 2003 work hour rules!!) has been strongly opposed to work hour rules since before their inception. Faculty members have been actively researching and looking for any data to show work hour rules are bad to get rid of them. The fact that no convincing data has yet been found to show that reducing resident work hours is harmful to patients or training has spoken volumes to me. This is despite the years of exhaustive work by some of the biggest names in clinical research.

And, yes, I don't feel that adequate training will happen during internship. For instance, laboring patients often take greater than 16 hours to deliver. Continuity of care is lost, which decreases learning.

They often take greater than 24 hours as well. But, if you're going to be delivering patients in your career you'll be doing more than one OB/GYN rotation as an intern, so I don't really see the problem.

This is all very political and has less to do with patient care and more to do with the news media and patient perception.

The ACGME is being pushed by the IOM--that much is true. Certainly a great deal of the input to the IOM has to do with outside advocacy groups. Nevertheless, you still have not given any evidence that patient care is affected by shift length. There is significant evidence that shift length does not have an effect on patient care outcomes--pre- and post- work hour rules studies, private hospitals that don't use residents, care in other countries that limit shift length, etc...

 

[PlutoBoy]

How much? I took an oath to do no harm. I can't, in good faith, practice effectively with these new guidelines and expect in the future to "do no harm". I owe that much to my patients.

Medicine is like no other field. This isn't just a job, this is a calling, and with that calling comes responsibility.

I understand, but how much is enough? You didn´t answer the question...

 

[1viking]

Fatigue is also a known problem that causes patient errors. There is no evidence that the reduction in fatigue is more or less important than the increase in handoffs.

Very true. Do you think reducing hours will decrease fatigue? Residents go home and don't stop...clean the house, pay the bills, etc...When I'm post-call, I don't sleep until that night. With the new 16 hour rule, If I go on at 8 PM and get off at noon, I won't go to bed until 11 PM. What is the point? I haven't gained rest and will be just as fatigued, if not more because I have 4 crazy kids at home.

The fact that no convincing data has yet been found to show that reducing resident work hours is harmful to patients or training has spoken volumes to me.

Very true. The correct question or model hasn't been asked/studied. I think our clinical skills of diagnosis are a reflection of the rules--->CT/MRI/US is how we diagnose today. Contrast exposure related malignancies will play a larger rule in the population 20 years from now, and this might be the answer we are seeking.

biggest names in clinical research.

Whatever this is supposed to mean

you'll be doing more than one OB/GYN rotation as an intern, so I don't really see the problem.

Continuity

There is significant evidence that shift length does not have an effect on patient care outcomes--pre- and post- work hour rules studies, private hospitals that don't use residents, care in other countries that limit shift length, etc...

so why change it if it makes no difference? I don't get it...we are in a health care crisis situation right now. We should be asked to work harder, not less. This makes no sense in terms of economic viability.

 

[1viking]

I understand, but how much is enough? You didn´t answer the question...

I don't know the answer to that question, but certainly not less than what we are doing now.

 

[Neuronix]

What is the point? I haven't gained rest and will be just as fatigued, if not more because I have 4 crazy kids at home.

I think you answered your own question. I mean, this isn't ostensibly why the rules were put in place--so we can have time for our lives and our families. But, that's why we should enjoy it.

This makes no sense in terms of economic viability.

I've found that this is typically what these discussions come down to.

The correct question or model hasn't been asked/studied.

Go for it my man. You obviously have the reasons why these rules are bad. Go prove you're right.

 

[JDWflash44]

I thought that the most interesting part of the article was the discussion of how the 80 hour rule will now be enforced. This is what stuck out to me the most:

"Recognition of the need for enhanced measures to promote compliance has led to a new program of annual site visits to sponsoring institutions, focusing on duty-hour compliance, supervision, and provision of a safe and effective environment for care and learning...The ACGME will provide each institution with a report that details its compliance status and identifies noncompliance issues for timely resolution. The plan is to make these results available to the public."

I think 80 hours with overnight call is fine, as long as it is enforced. The problem is there is no way to enforce it when all of the residents work 100+ hours and then put 80 on their time sheets. Maybe site visits ala CMS will cause programs to actually comply with the 80 hour limit, rather than relying on whistle blowers to identify programs that don't comply.

 

[dilated]

Fatigue is also a known problem that causes patient errors. There is no evidence that the reduction in fatigue is more or less important than the increase in handoffs.

I have inside knowledge about the studies that have been conducted in this area. The institution where I've been a student for seemingly ever now (since before the 2003 work hour rules!!) has been strongly opposed to work hour rules since before their inception. Faculty members have been actively researching and looking for any data to show work hour rules are bad to get rid of them. The fact that no convincing data has yet been found to show that reducing resident work hours is harmful to patients or training has spoken volumes to me. This is despite the years of exhaustive work by some of the biggest names in clinical research.

But why is it OK for PGY2-5 to pull 30 hours but not interns? I would be a whole lot more worried about the guy who's performing the emergent case than the guy who has to put in an order for tylenol and can call his senior if he's so tired he's not sure if he's doing the right thing. Either 30 hour calls are physiologically undesirable or they're not.

These rules are ******ed and only make sense if viewed from the perspective of how they'll play in the media (goal: a system that can't be easily digested by the public but will contain references to some resident doctors being changed from 30 to 16 hour shifts).

 

[1viking]

I think 80 hours with overnight call is fine, as long as it is enforced. The problem is there is no way to enforce it when all of the residents work 100+ hours and then put 80 on their time sheets.

Punishing all because of a few is wrong. My program has made it so that it is impossible to go over 80. Just when we got it all working, we are going to have to go back to the drawing board.

 

[Moonglow]

What does his response have to do with being a surgeon?

A question asked by surgeons every day in every hospital. 😀

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1891765/

 

[Winged Scapula]

A question asked by surgeons every day in every hospital. 😀

And every day, in every hospital, internists spend a lot of time mentally masturbating and fail to answer the questions asked of them in any clinically relevant, "what do we do now" fashion. 😀

 

[gutonc]

And every day, in every hospital, internists spend a lot of time mentally masturbating and fail to answer the questions asked of them in any clinically relevant, "what do we do now" fashion. 😀

What are you talking about? If we can't answer the question, we almost always suggest some other service to dump on. Usually rheum or endo.

 

[Moonglow]

Now WS, you know that internists don't want surgeons involved in medicine. So answers to questions are mumbled, waiting for the stomp-off and the trail of obscenities, knowing that all will be forgotten in a matter of minutes - part of the daily business of quality patient care.










😉

 

[Winged Scapula]

What are you talking about? If we can't answer the question, we almost always suggest some other service to dump on. Usually rheum or endo.

Now WS, you know that internists don't want surgeons involved in medicine. So answers to questions are mumbled, waiting for the stomp-off and the trail of obscenities, knowing that all will be forgotten in a matter of minutes - part of the daily business of quality patient care.










😉

I'm in the car driving to Ann Arbor with my aunt's BF, a retired IM PD who said, "you can't tell surgeons everything because then they'll try and run the show even more than they already do! The exception of course are orthopedic surgeons who don't want to know anything about medicine."

 

[Ronin2258]

And every day, in every hospital, internists spend a lot of time mentally masturbating and fail to answer the questions asked of them in any clinically relevant, "what do we do now" fashion. 😀

Thanks WS. That made my my frakking morning. 😀 One of the many things that made me want to be a surgeon, and when the condition made that impossible, anesthesiology. I wanted to do something definitive quick instead of waiting for the inevitable geek-gasm, *then* do something.

An old surgeon from school (former one-star general officer,) kept saying, "Surgeons are medicine doctors that offer definitive therapeutic modalities." Always kept that in the back of my mind, even in residency.

 

[alimarie81]

since these changes are likely to pass (per our program director), does anybody out there have any concrete ideas on how you are going to handle coverage of call at your program? our program has a residency of 10 per class year, traditional call schedule and cover two hospitals. is the only option night float, and having interns not take call because direct supervision means another senior resident will be used to supervise (and by proxy be taken out of the call schedule for the next few days); from a numbers standpoint, we cannot now provide all the coverage for overnight call in our hospital for our specialty, even with night float.

Anybody have ideas you have been discussing in your programs if you currently have a traditional call schedule and limited number of residents?

we are scrambling for ideas here as the attendings clearly are not wanting/able to take up the slack for the holes this creates

 

[Shikima]

I know what you mean. At our program, we have 3 hospitals to cover and only a handful of residents per year. The upper levels are dedicated to clinic and cannot cover call.

These guidelines are getting out of hand, the work increases and the bodies to do the work do not. I understand that faculty aren't interested as they've done their time and have other administrative properties in which to cover, however, something will eventually have to give.

How does one approach management with the sincere desire to have them on board with helping if the bottom-line is getting the work done (not so much education). In the process of doing the work, the education happens (which brings up a much grander discussion for another time and thread).