New IOM reccomendations for duty hours

[MGG1848]

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Just had new IOM reccomendations released today regarding changing duty hours. Check it out:

http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12022008a

Very aggressive new rules. 16 hours max continous time with 5 hours to sleep.

5 days of a month, 1 48 hour period off.

What does everyone think?

 

[dragonfly99]

I think we should work on enforcing the work hours rules we already have before creating more restrictive ones. I also think it's going to take away a lot of flexibility from programs in being able to design their schedules. I actually didn't mind 30 hour call so much, considering we had no night float...as long as the call had a reasonable number of admits, etc. I think there could be a lot of unintended consequences to these new rules, and I honestly don't see how a lot of surgery and internal medicine programs are going to be able to do this. It would take so many more interns to cover multiple 16 hour "shifts" vs. doing traditional Q4 30 hour call, I don't see how my residency program (to give just one example) would be able to do it.

I do think a 16 hour limit in the medical ICU (or thereabouts) for interns would be a good thing.

 

[zmeister22]

http://www.msnbc.msn.com/id/3032619/#28022811

Institute of Medicine today officially recommended changes in the resident education system. They recommend that no resident physician work more than 16 hours at once, and if they must be in the hospital for a 30 shift, they must have a 5 hour uninterrupted sleep break in the middle. They also call for better Dr. to Dr. patient hand off techniques.

Opinions?

 

[doc20]

I don't think they are limiting to a 16 hour shift,
but they are recommending a 5 hour break after a 16 hour shift for a continuous 30 + hr shift.. which I think is definitely going to help both the resident and patient care
overall the recommendations are good and if implemented will definitely help the intern years

 

[Danbo1957]

Rather damning report...

Comments and suggestions from the report indicate that problems still exist in getting the 2003 regulations implemented, and that negligent clinical care given to patients from residents in teaching hopitals continues.

 

[yaah]

There's a very similar thread on the same topic in this forum which has replies. Merging both.

 

[orientedtoself]

who is supposed to cover the patients and admissions while the resident on that night is getting their five hours of sleep?

16 hour shifts? not enough residents to cover all of our sites.

i'm glad i'll be outta here before this is implemented.

 

[yumita]

I for one would rather do a 4 year, slightly lower-paid residency, than the current standard 3 year stint in hell.

 

[dragonfly99]

If they really mandate a 5 hour sleep period, I don't see how that can be worked out except to have night float everywhere. It WOULD be nice for the interns, but if they are going to be "off" for 5 hours, the programs will all just probably make it a night float system...which means everyone will have to work harder on non-call days. I don't know, maybe it would work...I just can't imaging that my training would have been the same if I never spent a night in the hospital (other than a night float type situation). It WOULD be nice if they enforced the 1 day off in 7 (on average) and the 30 hour rule...even doing that would help a lot. I think that should come before imposing even more rules.

 

[lowbudget]

Ha. They think we're dumb or something. New recommendations means more time to moonlight (i.e. more docs out in the world independently with less training hours).

If they're really serious about me getting rest, IOM should recommend that all residents get an increase in their pay equivalent to the work they do.

That way, I can hire a maid, a concierge, a cook, a baby sitter, and a chauffer so I can get more sleep.

 

[dragonfly99]

I thought they were recommending prohibiting moonlighting?

 

[mcl]

I thought they were recommending prohibiting moonlighting?

Not prohibiting, exactly, but certainly limiting it:

"Internal and external moonlighting is counted against 80 hr weekly limit"

 

[dragonfly99]

That part seems fair (counting moonlighting against 80 hours/week). I mean, if we are supposed to be trainees and the argument for limiting the work hours to 80 was that residents/fellows need to rest, then it makes zero sense to limit the "official" work hours and then not count the external moonlighting.

 

[SoCuteMD]

That part seems fair (counting moonlighting against 80 hours/week). I mean, if we are supposed to be trainees and the argument for limiting the work hours to 80 was that residents/fellows need to rest, then it makes zero sense to limit the "official" work hours and then not count the external moonlighting.

Isn't moonlighting already counted against the 80 hours?

 

[Law2Doc]

Isn't moonlighting already counted against the 80 hours?

Some programs certainly already think/dictate so. And it makes sense -- if the point of these rules is to have well rested residents, it doesn't really work if you limit their hours to 80 and they do another 20 after their shifts are over.

 

[Law2Doc]

I for one would rather do a 4 year, slightly lower-paid residency, than the current standard 3 year stint in hell.

Except that a lot of residencies are already a lot longer than your 3 year stint, so folks on 5+ year paths probably wouldn't make the same trade.

 

[Law2Doc]

who is supposed to cover the patients and admissions while the resident on that night is getting their five hours of sleep?

Lots of night float?

 

[RTrain]

I guess it's possible there's something about the situation that I don't understand, but the way I see it, we already have a system (the current work-hours restrictions) that has been difficult to implement, is often disregarded, whose enforcement depends entirely on self-reporting, and is not fully supported by its community. Now there's a movement to make the system more restrictive. How is this not going to exacerbate the existing problems?

 

[Law2Doc]

I guess it's possible there's something about the situation that I don't understand, but the way I see it, we already have a system (the current work-hours restrictions) that has been difficult to implement, is often disregarded, whose enforcement depends entirely on self-reporting, and is not fully supported by its community. Now there's a movement to make the system more restrictive. How is this not going to exacerbate the existing problems?

Maybe the theory is that if you keep moving the target further, then folks will at least get to the prior set of implementation rules, which they aren't all getting to yet. Sort of like telling someone you know is notoriously late an earlier time to show up, in order to have them show up on time.

 

[Miami_med]

Maybe the theory is that if you keep moving the target further, then folks will at least get to the prior set of implementation rules, which they aren't all getting to yet. Sort of like telling someone you know is notoriously late an earlier time to show up, in order to have them show up on time.

Yes, except that this isn't the ACGME, this is an IOM report to congress. They have the ability to impose penalties for disobedience that go beyond probation or more frequent RRC reviews.

 

[Miami_med]

Your first thought for compliance would be to attempt to do away with traditional call and implement a night float. However, closer look at the recs also limits night float to no more than 4 days in a row, which essentially makes a night float impossible. The next argument would be to have every call taken with both a junior and senior in house, and they could cover each other's sleep break. However, interns aren't allowed to be alone in house under the new rules, and I'm not sure how a "sleep break" impacts this if the senior isn't allowed to assist the intern. I guess we could always have half the team come in in the morning and half in the afternoon.

The four hours of nights in a row limit is not only ridiculous (people work a night shift at many occupations), but it makes the only real way to comply for a lot of programs to have a rotating day/night schedule which is the only thing that has actually been proven to be bad for you in the long term. In order to prevent some residents from being tired after a call shift, we are going to force everyone into the one schedule that it is impossible to become well rested while keeping. This sort of shift swinging in EM leads to the highest use of stimulants and downers within any specialty, and they don't work anywhere near 80 hours as would still be required in the surgical specialties. This is frankly a little scary.

 

[Hurricane]

They want 50 bucks to read the actual report? That is lame. But I'm glad that physicians are finally applying evidence-based medicine to themselves and concluding that it's neither normal nor safe to function for 30 hours in a row without sleep. Maybe finally we can move away from a residency system that was based on the sleep habits of an admitted cocaine addict (Halstead).

 

[Law2Doc]

Your first thought for compliance would be to attempt to do away with traditional call and implement a night float. However, closer look at the recs also limits night float to no more than 4 days in a row, which essentially makes a night float impossible.

Not really impossible. You simply have two night float teams, doing 4 days in a row one week, then one to two days of day float, while the other team does the next 3 days in a row of night float plus one to two days of day float, and then switch. Or some other variation on that theme. It simply can't be the same folks doing night every night. But with multiple teams you can get to the total night float coverage goal, which allows everyone else to go home every night and not run afoul of the 16 hours in a row cap.

 

[Miami_med]

Not really impossible. You simply have two night float teams, doing 4 days in a row one week, then one to two days of day float, while the other team does the next 3 days in a row of night float plus one to two days of day float, and then switch. Or some other variation on that theme. It simply can't be the same folks doing night every night. But with multiple teams you can get to the total night float coverage goal, which allows everyone else to go home every night and not run afoul of the 16 hours in a row cap.

I guess that might be true for some larger residencies. As someone applying to surgery, the largest group that I've seen is 9 residents/year at any place that I've interviewed, and that often covers up to 5 hospitals. There is simply not enough manpower. Especially if you consider that the largest group in your program (interns including prelims) cannot be alone at any time during call, even with home backup. It would also require more schedule shifting, more months of going back and forth from days to nights to days, and less exposure to the formal teaching. You are probably right in the sense that some of the larger programs could simply have 2 simultaneous night floats, but it wouldn't work out for groups as a whole.

Also, the humane things that have actually started to come out under the 80 hour work week will actually regress under these new rules. It makes golden weekends harder, vacation coverage harder, and it will clearly cause a shift in the number of hours devoted to productive efforts towards scut.

At this point, there is no evidence that there has been a reduction in errors in the post vs. pre-80 hour week period. As we implement more patient safety measures, it will become impossible to tease out what is the result of work hour reforms and what is the result of greater scrutiny within the system. One might say that this benefit is for the residents. However, it is clear that there are a LARGE number of residents, if not the majority, that are opposed to further changes.

With no clear evidence-based reason for the current recs, and no real push from the programs, the residents, or even most patients to change anything yet, I see zero reason to impose a bunch of rules that only serve to make complying with work hour restrictions more difficult. I also wonder if it might be time for some of the surgical specialties to break away from the IOM, which clearly has no understanding of anything that happens in surgical training or practice.

 

[RTrain]

I guess that might be true for some larger residencies. As someone applying to surgery, the largest group that I've seen is 9 residents/year at any place that I've interviewed, and that often covers up to 5 hospitals. There is simply not enough manpower. Especially if you consider that the largest group in your program (interns including prelims) cannot be alone at any time during call, even with home backup. It would also require more schedule shifting, more months of going back and forth from days to nights to days, and less exposure to the formal teaching. You are probably right in the sense that some of the larger programs could simply have 2 simultaneous night floats, but it wouldn't work out for groups as a whole.

Also, the humane things that have actually started to come out under the 80 hour work week will actually regress under these new rules. It makes golden weekends harder, vacation coverage harder, and it will clearly cause a shift in the number of hours devoted to productive efforts towards scut.

At this point, there is no evidence that there has been a reduction in errors in the post vs. pre-80 hour week period. As we implement more patient safety measures, it will become impossible to tease out what is the result of work hour reforms and what is the result of greater scrutiny within the system. One might say that this benefit is for the residents. However, it is clear that there are a LARGE number of residents, if not the majority, that are opposed to further changes.

With no clear evidence-based reason for the current recs, and no real push from the programs, the residents, or even most patients to change anything yet, I see zero reason to impose a bunch of rules that only serve to make complying with work hour restrictions more difficult. I also wonder if it might be time for some of the surgical specialties to break away from the IOM, which clearly has no understanding of anything that happens in surgical training or practice.

Completely agree that trying to implement more restrictive work hour requirements will serve only to erode educational time and stretch manpower far too thinly to allow reasonable scheduling.

Further, it's not just the surgical specialties that have reason to believe that the IOM has zero understanding of the realities of practice - I think it's probably any hospital-based specialty. My IM program, for example, is based at such a busy county hospital that we have no fewer than 5 different teams/floats taking admissions each day to handle all the ER admissions without going over "cap." If no one could stay overnight for call, that would probably increase to 8. Bye bye, electives.

Thank FSM I'll be done with residency before this would have a prayer of being implemented.

 

[Faebinder]

They want 50 bucks to read the actual report? That is lame. But I'm glad that physicians are finally applying evidence-based medicine to themselves and concluding that it's neither normal nor safe to function for 30 hours in a row without sleep. Maybe finally we can move away from a residency system that was based on the sleep habits of an admitted cocaine addict (Halstead).

 

[howelljolly]

Not really impossible. You simply have two night float teams, doing 4 days in a row one week, then one to two days of day float, while the other team does the next 3 days in a row of night float plus one to two days of day float, and then switch. Or some other variation on that theme. It simply can't be the same folks doing night every night. But with multiple teams you can get to the total night float coverage goal, which allows everyone else to go home every night and not run afoul of the 16 hours in a row cap.

Exactly...

Interesting.... I suppose your guys are correct in that if some residents dont work marathon shift, others will have to do more nights.... and miss out on daytime formal teaching.

 

[Taurus]

If these recs ever become accepted, there's no doubt there will be an even greater utilization of midlevels. As anyone who reads my post, I vehemently oppose the encroachment of midlevels into medicine, especially by the NP's. However, I think that forcing someone to take call where you typically work 30 hours straight every 4 days is simply evil. At times I feel that medical education and medicine in general is so %&*#'ed up.

 

[dragonfly99]

I think inpatient-heavy IM programs would have a really hard time under these new rules also. I think that it would be fine to do night float 5-6 days in a row...nights aren't that bad once your body adjusts and besides it's usually just a 12 hour shift or less...cake for those of us used to the 30 hour ones. You'd need a damn lot of residents to implement this new system in medicine programs...the big ones with 40 interns could probably do it, but I don't see how small programs could do it. I don't see how the vast majority of surgical programs could do it either. I think you'd have a ton of people missing out on formal teaching rounds as well.

I do support mandating that both external and internal moonlighting should be part of the 80 hours/week limit. It doesn't make sense to even have the limit if moonlighting isn't included.