New Resident work hours = big problems

[jokerabc]

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These new work hour rules for PGY1s and having close supervision with senior level residents is going to really change how residency programs work. We are changing so many things in our residency yet. The rule will most likely take effect July 2011, and our hospital wants to implement changes before that for a smooth transition.

Especially a problem for the seniors, they have to work more and take call b/c PGY1 cannot work as much, and need supervision. This is bad for programs that are "front-heavy" and where seniors dont take as much call.

What are some of your guys programs doing? As this new 16 hour rule kind of creates a shortage?

 

[C5toC9]

can you briefly summarize the big changes?

 

[Ronin2258]

http://acgme-2010standards.org/proposed-standards.html

Interns are no longer pulling call (24+6)
Interns are limited to 16 continuous hours in the hospital
Interns must be supervised by a higher up.

I feel the interns are going to have less responsibility than they should.

Anyone on here sit on the ACGME committee for this?

 

[mcl]

http://acgme-2010standards.org/proposed-standards.html

Interns are no longer pulling call (24+6)
Interns are limited to 16 continuous hours in the hospital
Interns must be supervised by a higher up.

I feel the interns are going to have less responsibility than they should.

Anyone on here sit on the ACGME committee for this?

I attended an educational conference for my specialty which featured a member of the ACGME Committee discussing the duty hour recommendations in detail. Some elements are tightening, some elements are loosening, and many elements of the recommendation reach farther than specific duty hours to include fatigue recognition and mitigation, criteria for being considered "fit for work," and development of structured handoff processes to ensure patient safety. Individual RRCs will have leeway to limit the patient load for residents by level, define terms such as intermediate vs. senior resident, or determine parameters of Night Float rotations regarding number of consecutive days and/or number of consecutive weeks.

Institutions will be monitored annually by the ACGME and given a letter grade, posted on their website, reflecting compliance with whatever the new rules end up being. The public comment period expired on 8/9. The committee will meet again in the fall to review the comments they received and make changes. They expect to send a final draft to the Program Requirements committee in the fall and implement the new regulations as of July 2011.

 

[dpmd]

The intern supervision requirement doesn't seem that bad (at least the way I interpreted it). Are there places where the intern has no senior in house with them?

 

[hippiedoc13]

The intern supervision requirement doesn't seem that bad (at least the way I interpreted it). Are there places where the intern has no senior in house with them?

This is the case at my program. Our interns take call alone. Requiring direct senior supervision of interns is going to affect the structure of our 3rd and 4th years in a significant way (just in time to affect my class, hooray).

 

[Doctor Bagel]

The intern supervision requirement doesn't seem that bad (at least the way I interpreted it). Are there places where the intern has no senior in house with them?

We don't have inhouse supervision here either. The attendings stay at home, and we call them regarding anything significant (all admissions, discharges, consults, etc.). We also have a senior resident on backup, but they're not in house, and we generally don't contact them. How it works now is that we have a significant amount of call first and second year with nothing except home backup call third and fourth year. Requiring inhouse upper level resident supervision has the potential to make residency a lot harder for me and others in my class.

 

[dpmd]

I forgot about nonprocedural residencies, and was just thinking about some surgery or maybe an IM intern being left all alone to handle things and how that would invite disaster. I can't tell whether the reg wants direct or indirect (with someone in house) at all times, or just for big things. If it is just for big things (like changes in code status, sick patient, procedures) that don't happen much in your field then it won't change much. This was how I interpreted it, but that may be too logical a thought process for these people).

 

[mcl]

I forgot about nonprocedural residencies, and was just thinking about some surgery or maybe an IM intern being left all alone to handle things and how that would invite disaster. I can't tell whether the reg wants direct or indirect (with someone in house) at all times, or just for big things. If it is just for big things (like changes in code status, sick patient, procedures) that don't happen much in your field then it won't change much. This was how I interpreted it, but that may be too logical a thought process for these people).

The slide I saw regarding supervision said "PGY 1 residents must receive either direct supervision (the supervising physician is physically present with the resident and patient) or indirect supervision 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). This supervising physician may be an upper level resident (with the indivisual RRCs having discretion to define the term "upper level").

 

[dpmd]

Yes but supervision during every minute of the day, or just for things that meet certain criteria?

 

[hippiedoc13]

Yes but supervision during every minute of the day, or just for things that meet certain criteria?

I believe they mean for every minute of the day. That is also how every program I know is interpreting it, as they frantically try to figure out how they're going to meet that standard come July.

 

[hippiedoc13]

I forgot about nonprocedural residencies, and was just thinking about some surgery or maybe an IM intern being left all alone to handle things and how that would invite disaster.

Actually there is a surgery service at our hospital system that has interns taking in-house call alone, with a senior on home call for backup. At least that's how it was when I was an intern on that service. We have two hospitals, and this is at the smaller one. The intern is in-house alone overnight to see ER consults and manage the post-op floor and ICU patients alone. If an ICU patient was tanking, or if there was a case to go to the OR in the middle of the night, the senior would usually be called in to operate. But if the OR case was an intern-level case (eg, an appy), then sometimes just the attending would come in and the intern would operate.

 

[starbuckscoffee]

My program is very concerned about how we will create resident schedules that comply with the proposed 16 hour PGY1 rule.

Does anyone have good ideas? I've heard there are some programs that don't have PGY1s do 24 hour calls already. Does anyone know what type of schedules have been used? The problem I see is that the night float can only do 6 days in a row, so you need the day team to stay overnight at least 1 day out of 7. I guess you could pull someone from an elective to do night float for 1 night, but this doesn't sound ideal.

 

[edmadison]

My program is very concerned about how we will create resident schedules that comply with the proposed 16 hour PGY1 rule.

Does anyone have good ideas? I've heard there are some programs that don't have PGY1s do 24 hour calls already. Does anyone know what type of schedules have been used? The problem I see is that the night float can only do 6 days in a row, so you need the day team to stay overnight at least 1 day out of 7. I guess you could pull someone from an elective to do night float for 1 night, but this doesn't sound ideal.

Likely, an intern night float system would solve most of these problems. On the 7th day, you'd could either do a short call of another intern, or cover it with a random senior. I think that big programs will be able to absorb these new rules with a night float system. Small programs, however, will not have enough interns to cover both day and night. They may just choose to hose the seniors and have the interns take call from 6am-10pm. Fun to be a senior then, huh?

Ed

 

[MojoRisin]

can you briefly summarize the big changes?

pgy1 ~ ms5

 

[smq123]

They may just choose to hose the seniors and have the interns take call from 6am-10pm.

With interns, could they have them work from 6 AM to 6 PM, "signout," go home/take a mandatory "nap" for 4 hours while the senior covers until 10 PM, and then return for a night time "call" from 10 PM to 6 AM? It'd suck, but it would technically fulfill the rules....

 

[michaelrack]

With interns, could they have them work from 6 AM to 6 PM, "signout," go home/take a mandatory "nap" for 4 hours while the senior covers until 10 PM, and then return for a night time "call" from 10 PM to 6 AM? It'd suck, but it would technically fulfill the rules....

What's wrong with that? It's much better than the schedule I had when I was an intern.

 

[smq123]

What's wrong with that? It's much better than the schedule I had when I was an intern.

I meant more that it would suck from a scheduling/logistics point of view. That, and for the senior who would have to take long call instead of just going home at 6 PM. That being said, it's better than making the seniors take overnight call, while the interns get no overnight call.

 

[P Diddy]

With interns, could they have them work from 6 AM to 6 PM, "signout," go home/take a mandatory "nap" for 4 hours while the senior covers until 10 PM, and then return for a night time "call" from 10 PM to 6 AM? It'd suck, but it would technically fulfill the rules....

I think you need 10 hours between shifts.

p diddy

 

[hippiedoc13]

My program is very concerned about how we will create resident schedules that comply with the proposed 16 hour PGY1 rule.

Does anyone have good ideas? I've heard there are some programs that don't have PGY1s do 24 hour calls already. Does anyone know what type of schedules have been used? The problem I see is that the night float can only do 6 days in a row, so you need the day team to stay overnight at least 1 day out of 7. I guess you could pull someone from an elective to do night float for 1 night, but this doesn't sound ideal.

Intern night float + a senior taking 24h call on the weekend.

Or, intern night float + 2 interns splitting a 24h shift on the weekend days. Supervised by an in-house senior, of course... 🙁

 

[smq123]

I think you need 10 hours between shifts.

p diddy

Well, not if you label it as "home call."

 

[P Diddy]

Well, not if you label it as "home call."

That would be perhaps the quickest path ever toward a loss of accreditation, since the interns would be in house for 8 hours every night rather than at home, and the ACGME would find out eventually.

p diddy

 

[Coastie]

pgy1 ~ ms5

👍

 

[Coastie]

http://acgme-2010standards.org/proposed-standards.html

Interns are no longer pulling call (24+6)
Interns are limited to 16 continuous hours in the hospital
Interns must be supervised by a higher up.

I feel the interns are going to have less responsibility than they should.

Anyone on here sit on the ACGME committee for this?

Who came up with these stupid rules? The same folks who are supporting Obamacare through their influence in the AMA and AAFP?

 

[colbgw02]

I did my internship under the first-round of ACGME work hour rules (24+6 hrs call shifts, average 1 day off in 7), and the work hours never felt overwhelming. Internship sucked, of course, but I never felt like I was in danger of hurting someone because I was too tired. So why the change? Is there some evidence that the system isn't working and needs reform? Or are they just bored?

 

[VA Hopeful Dr]

With interns, could they have them work from 6 AM to 6 PM, "signout," go home/take a mandatory "nap" for 4 hours while the senior covers until 10 PM, and then return for a night time "call" from 10 PM to 6 AM? It'd suck, but it would technically fulfill the rules....

Nope. You have to have 8 hours of uninterrupted time between shifts.

 

[smq123]

That would be perhaps the quickest path ever toward a loss of accreditation, since the interns would be in house for 8 hours every night rather than at home, and the ACGME would find out eventually.

p diddy

Well, maybe. But it does fulfill the letter of the law, if not the spirit.

I don't know - I don't know if there are any good solutions for small programs. 😕

 

[akoult]

Our program (NE, university, 3 hospital system, IM) is debating this as we speak. Depending on the kind of rotation one's on, it's either NF or call based.

This proposal will essentially switch all rotations to a NF system. Most of the proposals to deal with the issue of getting interns out early all revolve around getting residents to work more shifts. In the long term, we will probably have to increase recruitment, though that leaves unanswered the obvious question of funding.

I do however wonder what the surgeons, especially the neurosurgeons have to say about this. I don't see an aspiring surgical intern checking out of the hospital after 16 hrs and passing up the chance to assist in the OR. I especially don't see the neurosurgeons leaving after a said number of hours.

 

[Buzz Me]

I do however wonder what the surgeons, especially the neurosurgeons have to say about this. I don't see an aspiring surgical intern checking out of the hospital after 16 hrs and passing up the chance to assist in the OR. I especially don't see the neurosurgeons leaving after a said number of hours.

😕 Why would neurosurgery residents, in particular, have a problem with this (over any other surgical field)?

 

[Dr.LeoSpaceman]

The intern supervision requirement doesn't seem that bad (at least the way I interpreted it). Are there places where the intern has no senior in house with them?

Yes. I'm a GS intern, and we don't have an in-house senior for night float or weekend call. At first, I was a bit nervous about it, but it's not that bad. There are people around if you need immediate help (crit care attendings for codes/procedures and the trauma/ACS seniors who are always in-house). It's made pretty clear that you are supposed to have a low threshold for calling the senior/chief who is on home call, and they are all very good about not biting people's heads off if you do (assuming you have the appropriate info when they ask). It also helps that with home access to the EMR, they can check labs/imaging for themselves.

 

[gutonc]

There are people around if you need immediate help (crit care attendings for codes/procedures and the trauma/ACS seniors who are always in-house).

This is how I assume many larger surgery programs (and IM and Peds) will get around this issue. A senior resident on some rotation (Trauma, SICU, MICU, NICU, etc) will always be in-house and will be the designated "supervisory resident" for all in-house interns in that specialty.

 

[edmadison]

This is how I assume many larger surgery programs (and IM and Peds) will get around this issue. A senior resident on some rotation (Trauma, SICU, MICU, NICU, etc) will always be in-house and will be the designated "supervisory resident" for all in-house interns in that specialty.

I'm not sure this would fly. Under accreditation rules, supervision is required by those on the particular service. Whether this would be extrapolated to the ACGME rules is unclear. I am skeptical that the ACGME would let an inhouse senior or attending on a completely different service serve as a "supervisor". Now if you carefully rewrote the rotation description, that may work: e.g. it's now a SICU/ward rotation.

Ed

 

[ASA6]

I forgot about nonprocedural residencies, and was just thinking about some surgery or maybe an IM intern being left all alone to handle things and how that would invite disaster. I can't tell whether the reg wants direct or indirect (with someone in house) at all times, or just for big things. If it is just for big things (like changes in code status, sick patient, procedures) that don't happen much in your field then it won't change much. This was how I interpreted it, but that may be too logical a thought process for these people).

At a hospital I rotate at, the surgery intern is alone at the hospital at night and after about noon on the weekends. They cover every surgical specialty, including cross covering, admitting, and seeing consults. If they have questions and after seeing a consult, they call the chief resident of that service at home. Rarely do the come in. There is no surgery resident other than a pgy1 in house.

 

[ASA6]

Likely, an intern night float system would solve most of these problems. On the 7th day, you'd could either do a short call of another intern, or cover it with a random senior. I think that big programs will be able to absorb these new rules with a night float system. Small programs, however, will not have enough interns to cover both day and night. They may just choose to hose the seniors and have the interns take call from 6am-10pm. Fun to be a senior then, huh?

Ed

at a hospital a friend of mine works at, someone who is on an ambulatory rotation has to do a weekend night float shift, once during their month. that solves that problem. At a hospital i rotate at, there are 2 interns on night float, and they alternate nights. It makes it actually a fantastic rotation.

 

[mcl]

At a hospital I rotate at, the surgery intern is alone at the hospital at night and after about noon on the weekends. They cover every surgical specialty, including cross covering, admitting, and seeing consults. If they have questions and after seeing a consult, they call the chief resident of that service at home. Rarely do the come in. There is no surgery resident other than a pgy1 in house.

This is the kind of thing that programs will have to change.

My impression from the talk I heard was that individual RRCs would set up their own parameters for supervision. Some may accept an established scenario in which an in-house attending or senior resident from one specialty systematically privides the needed direct or indirect supervision for a PGY 1 resident in another specialty. Other RRCs might insist that the supervision be provided within the specialty. What seems clear to me is that home call supervision for the Interns won't be an acceptable scenario.