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Resident Restructure: Attendings adjust to new work-hour rules

by Richard Quinn •

One of her biggest concerns is that because of the new hours limit, PGY-1s won’t be able to participate in calls that provide basic knowledge necessary for advancement in subsequent years of residency.

“It eliminates the ability for them to take any kind of overnight call,” Dr. Franzese said. “It moves the learning experience backwards when a medical student can take [an] overnight call and an intern can’t. They’ve graduated from medical school, and this is the only time they get to learn to be a doctor. Valuable learning opportunities will be missed.”

Adjustments

There is disagreement, however, on how deleterious that effect will be.

“We may have to make up any deficiencies in the PGY-1 [when residents are] in the PGY-2 and PGY-3 years,” said Evan Reiter, MD, FACS, associate professor and residency program director of otolaryngology-head & neck surgery at Virginia Commonwealth University Health System in Richmond. “But I don’t see any long-term deficiencies.”

Dr. Reiter said one area to focus on with the new limitation is transitions of care. As PGY-1s work curtailed hours, there will likely be a noticeable increase in the number of patients whose jurisdiction passes from one resident to another.

“The handoff of care must continue to be thorough and complete,” he said. “If your shift is over at 16 hours, you have to make sure the guy coming on is aware of everything going on with all the patients.”

He said the new rules balance the need to ensure that residents are rested with the flexibility needed to provide them the education, both didactic and clinical, that prepares them to be physicians.

All the program directors and otolaryngologists interviewed suggested that their academic hospitals are likely to adjust to the new rules more easily than they did to the 2003 guidelines that some considered drastic.

Still, Dr. Sinacori said the newest rules are indicative of a “generational shift” in residents, in which young physicians view caring for themselves as just as important as taking care of their patients.

“We’ll survive and, for the most part, we’ll have good residents,” Dr. Franzese said. “But it will be a challenge.”

New Rules 101

The new ACGME requirements have drawn a lot of attention, but the rules could have been tighter. In 2008, the Institute of Medicine (IOM) published a report that stated that medical errors could be reduced by having residents take an uninterrupted five-hour nap for each 16-hour shift worked. Instead, the new rules capped a first-year resident’s shift at 16 hours and allowed more senior residents to work 24-28 hours, provided their programs encourage strategic napping and alertness management strategies.