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Resident Restructure: Attendings adjust to new work-hour rules

by Richard Quinn •

The new duty hour regulation from the Accreditation Council for Graduate Medical Education (ACGME) that limits first-year residents to 16-hour shifts has drawn a conflicted chorus of reactions from attendings, who have only seven months before the stipulation goes into effect.

Some otolaryngologists view the move ambivalently, seeing it as a natural extension of the landmark 2003 rules that capped most resident workweeks at 80 hours and required one day off in seven from all education and clinical activities. Others view it as yet another rule that chips away at how well prepared the next generation of residents will be.

Regardless of viewpoint, residency program directors have little time to prepare for the changes, which were formally adopted in late September and go into effect July 1. Because otolaryngology residents typically spend one to three months of their first year in the otolaryngology service, several program directors have said that the effect of the duty hour modification for post-graduate year one (PGY-1) residents may be muted on the physical ENT rotation. It could cause scheduling issues with other rotations the resident is on in that year, however, including anesthesiology and general surgery.

“Our PGY-1 otolaryngology residents who are rotating on the general surgery services? Those general surgery services are going to have more difficulty in staying in compliance,” said Bradley Kesser, MD, associate professor and program director of otolaryngology-head and neck surgery at the University of Virginia Health System in Charlottesville.

Dr. Kesser co-authored a report, “Four years of accreditation council of graduate medical education duty hour regulations: Have they made a difference?” which stated that the 2003 rules “did not improve patient care as measured by the 30-day readmission rate, in-hospital mortality, and patient’s length of stay” (Laryngoscope. 2009;119(4):635-639). The study, a retrospective review of an otolaryngology residency program’s resident duty hours violations and Otolaryngology Training Examination (OTE) scores, noted that residents’ performance on the OTE also showed no significant change. It suggested more research to determine whether the rules have had a statistically significant impact on either patient care or how well residents were trained.

Dr. Kesser said the rules will benefit upper level residents because the ACGME has added language that allows them to exceed previous duty hour limits in prescribed situations. Particularly noteworthy to Dr. Kesser is language that recognizes that “residents in the final years of education (as defined by the Review Committee) must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or extended periods.”

“Upper level residents need experience with extended shifts and extended duty hours,” he added. “After residency, in practice, there are no restrictions.”

“It moves the learning experience backwards when a medical student can take [an] overnight call and an intern can’t.”
—Christine Franzese, MD, FAAOA

Poor Preparation

John Sinacori, MD, FACS, director of the otolaryngology residency training program at Eastern Virginia Medical School in Norfolk, said that residents need to be taught the realities of the duty hours expected post-residency and added that the new ACGME rules are a setback to that preparation. He said his 10 fellowship-trained attendings are already discussing the potential impacts of decreased workloads for PGY-1 students and added requirements for supervision. (See “New Rules 101.”)

The burden of supervision and clinical work is not expected to be as great on otolaryngology faculty as it is on other educators, particularly those in internal medicine. Dr. Sinacori, however, fears that educators who are overburdened with non-teaching duties may begin to feel that the extra requirements are taking time away from the work that drew them to academic medicine in the first place.

“We have a very young group, we have a passion for teaching,” he said. “But already I hear these frustrations.”

Dr. Sinacori said the 16-hour limit, while well-intentioned in the vein of patient safety, is somewhat arbitrary in that it “magically” jumps to 24 hours on the day residents start their second year of training; the 24-hour limit remains in place for all subsequent years.

He suggested that a 16-hour shift could be a useful transition period for PGY-1s, but that the adjustment from medical school to residency schedules should take no longer than a month, maybe two. He added that the limit on duty hours does not address patient safety directly because residents are not guaranteed to take a nap or rest quietly once their shortened shift is complete.

“We cannot ensure that the tired resident is going home and resting before starting their next shift,” Dr. Sinacori said.

In fact, the reduced workload leaves residents less prepared as they enter their second and subsequent years, said Christine Franzese, MD, FAAOA, associate professor and residency program director of otolaryngology and communicative sciences, at the University of Mississippi Medical Center in Jackson, Miss. Dr. Franzese, as chair of the Society of University Otolaryngologists-Otolaryngology Program Directors Organization (SUO-OPDO), was on a panel discussing the new duty hours at the group’s annual meeting in October.

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.

Perhaps just as noteworthy, though, are the new guidelines on resident supervision. In the 2003 duty hours mandate, supervision was defined as a residency program ensuring that “qualified faculty provide appropriate supervision of residents in patient care activities.” But in the rules taking effect in July, that definition is further honed. First-year residents now require either direct supervision or what is called “direct supervision immediately available,” meaning that “a supervising physician is physically within the confines of the site of patient care.” In addition, senior residents are now expected to take supervisory positions over junior residents.

Other highlights of the new rules:

  • Intermediate level residents are required to have at least eight hours between scheduled duty periods, though 10 hours are recommended.
  • Moonlighting is now forbidden for first-year residents.
  • Two rules that have not changed: Residents must still be scheduled for a minimum of one duty-free day every week, averaged over four weeks, and duty hours are capped at 80 hours, including in-house call activities and moonlighting. Exceptions, which can add a maximum of 10 percent, or eight hours, must be based on “sound educational rationale.”