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Tuesday, November 2, 2010

Residency Duty Hour Changes

I am curious what the opinions are of some of the other Physician wives here for the new duty hours approved this past month by the ACGME.

You can find the new Common Program Requirements here. I am specifically referencing the section that begins on page 16 section VI.G - Resident Duty Hours.

Here is a quick run down of the way it will stand for all Residents beginning next July:

Maximum 80 work week averaged over a 4 week period (not changed)
Moonlighting counts towards 80 hour work week Max. (change)
PGY-1 not permitted to Moonlight
One day free of Duty for every one week period averaged over a 4 week period
Duty Hours for PGY1 CANNOT exceed 16 hours in duration (down from 30)
Duty Hours for PGY2 and Above cannot exceed 28 hours in duration (down from 30)
PGY1 Minimum 8 Hours off between shifts
Intermediate Minimum 8 hours off between shifts--14 hours duty free after in house 24 hour period

Residents must not be scheduled for more than six consecutive nights of night float.

PGY-2 residents and above must be scheduled for in-house call no more frequently than every-third-night (when averaged over a four-week period).

Time spent in the hospital by residents on at-home call must count towards the 80-hour maximum weekly hour limit.

Here are my thoughts and opinions:
I know that to the medical student wife looking at residency next year, 16 hour max shifts probably look great! As I have thought about this over the past couple months, i really think that this will be a dis-service to residents, especially those who are in surgical specialties, but really across the board. While I do think as a wife this will be great, I think that it really cuts back on the experiences a new resident can get. It will force many programs to go to a night float system, since they will no longer have the first year residents to rotate through a over night call system. Cutting the max shift down to 28 hours, means that for a surgical specialty resident who starts his day at 5:00am, they must be off by 9am the next day. To me, seeing what my husband has worked, this doesn't seem possible, practical, or reasonable from a patient standpoint. Maybe I am way off, but it just seems like the doctors that will be trained will not benefit as much from some of the training they will miss you on. But as a PGY1, only being allowed to work 16 hours, that cuts out so MANY experiences you could have. But that is just my 2 cents.

Like I said, I really want to see some other people's opinions on this. Are you worried? Are you happy? Were you aware of the potential changes coming, or that any changes were even taking place?

25 Comments:

Marv Loucks said...: I hope this isn't out of place to put this year, I thought it would be a good way to make sure people aware and find out opinions!; November 2, 2010 at 8:54 PM
Stephanie said...: i don't like it. for a few reasons:

1. it seems like residency may end up being more years {obviously, not now, but at some point} and this journey takes enough years in my opinion.

2. i don't like the government regulating things, because they don't seem to have the common sense end of things figured out. i don't like them involved in regulation of medicine -- what happens if they start limiting time frame attendings can work?

3. i think it will be very stressful to the residents - my husband is in ortho, they are always busy, and i can't imagine that these limitations are a step in the right direction to having them take care of the needs of a very busy level I trauma center.

i think that they patients are the ones that suffer in the end.

but, as my husband points out, i don't have any first hand knowledge of this...i am just speculating. it seems like a bad idea to me...; November 2, 2010 at 9:10 PM
Diane said...: I would like to begin with, in addition to Stephanie's statement of: I don't have first hand knowledge (according to my husband, too!) but I'd like to add my personal opinions.

1. In my hubby''s ex-residency program there were PG-years that were short-handed of residents; who will cover the shifts when all residents have max-ed out?

2. I'd be lying if I denied the fact that I'm a bit jealous for this new regulation not being implemeneted sooner. My hubby took quite the beating during residency BUT, because of it, he is a heck of doctor.

and...

3. I truly feel that incoming residents will fall short of fully benefit-ing from the many wonders medicine offers.; November 2, 2010 at 10:36 PM
Laura said...: 110% AGREE. Jake will be starting residency in June. This is a HOT topic with the 4th year medical students. Of course -- we're all clueless about residency -- but husband and I are not on board with the new regulations. How can an overhead manage a hospital that it knows nothing about -- especially the patient population???

HEY PEOPLES. Our parents' generation says that this "X" generation (us!) are complete whimps when it comes to residency hours. HA! It's so curious to hear perspectives!!!

If you signed up to be with a resident for life -- the journey is long, grueling, and draining for all -- but it's all temporary. We signed up for this folks....; November 3, 2010 at 7:16 AM
Mrs said...: Let's just say we should all be seriously worried if, God forbid, we should ever require hospitalization in the future because these new residents will be ill equipped to deal with the demands of medicine AFTER residency. I agree with the post that mentions that there is no way a surgical resident can have adequate experience with this. You cannot regulate patients from not having a medical crisis after business hours, so you cannot treat this training period like some desk job. Furthermore, as an ICU RN, even I can handle working over 16 hours straight. I often worked 18 hour shifts with less than 8 hours off between shifts. I have even worked 24 hours straight and it gave me a profound respect for what these residents endure daily. If your doctor cannot think straight because he is used to having beauty sleep, if he is irritated because he never had to deal with a crisis after hours, he should not be called a doctor. There is no substitute for the experiences and expertise achieved under countless hours of stress & fatigue. If you turn medicine into shift work, you run the risk of having doctors who fail to deliver continuity of care because their brains are used to turning off at the 16th hour. Seriously, women have long withstood being in labor longer than that. These new regulations do nothing good for the profession as a whole.; November 3, 2010 at 7:59 AM
Mrs said...: Let's just say we should all be seriously worried if, God forbid, we should ever require hospitalization in the future because these new residents will be ill equipped to deal with the demands of medicine AFTER residency. I agree with the post that mentions that there is no way a surgical resident can have adequate experience with this. You cannot regulate patients from not having a medical crisis after business hours, so you cannot treat this training period like some desk job. Furthermore, as an ICU RN, even I can handle working over 16 hours straight. I often worked 18 hour shifts with less than 8 hours off between shifts. I have even worked 24 hours straight and it gave me a profound respect for what these residents endure daily. If your doctor cannot think straight because he is used to having beauty sleep, if he is irritated because he never had to deal with a crisis after hours, he should not be called a doctor. There is no substitute for the experiences and expertise achieved under countless hours of stress & fatigue. If you turn medicine into shift work, you run the risk of having doctors who fail to deliver continuity of care because their brains are used to turning off at the 16th hour. Seriously, women have long withstood being in labor longer than that. These new regulations do nothing good for the profession as a whole.; November 3, 2010 at 8:00 AM
Adriana said...: We are both really thankful that the new regulations will be implemented after we are done with residency. For our program (OB/GYN) the biggest difference is how they will now cover weekends and the labor floor on days/night. Right now they split weekends up in two shifts. Friday night and all day Sunday is one shift and the second shift is 24 hours on Saturday. With the new regulations the residents will no longer be able to cover the weekends this way. This means more weekends but less hours. Our experience is that a weekend is shot when they are on call. I would rather them work the 24 hours and be done rather than have them work more weekends but less hours. They also cover the labor floor in a day shift and night shift right now. Again because of the new night float regulations this will have to change the way they have it set up. Our residents have been meeting constantly trying to figure out the best way to work the new regulations into their scheduling. People have very strong opinions that are not all the same.; November 3, 2010 at 8:59 AM
Camilla Millar said...: As my hubby is in his 4th year of surgical training, I can say this will be devastating to the learning opportunities for interns. They learn so much while on call. This will probably also have the effect of giving them even less time in the O.R. than they already have.

That part about home-call hours being counted toward totals is ludicrous. I don't see how the 'slower' services which have home call because they aren't generally as busy at night will deal with this. It totally means the residents might as well be at the hospital, so we'll see them less.

28 hours versus 30-- just means the residents will lie more. If there is any place the residents fudge the numbers it is by saying they leave the hospital sooner than they actually do.

For surgery these guidelines are a recipe for work-hour restrictions. I personally don't see how the work will get done.; November 3, 2010 at 7:49 PM
Camilla Millar said...: Oh, might I also add that in surgical professions, I see every resident needing to do a fellowship in order to learn basic skills.; November 3, 2010 at 7:56 PM
Cheri said...: This comment has been removed by the author.; November 3, 2010 at 9:04 PM
Cheri said...: This comment has been removed by the author.; November 3, 2010 at 9:09 PM
Cheri said...: This comment has been removed by the author.; November 3, 2010 at 9:10 PM
R said...: I think all the regulations are good except for the "Duty Hours for PGY1 CANNOT exceed 16 hours in duration (down from 30)." That is lame. Why all of a sudden can they take 28 hours as a PGY2? They need to learn by seeing aLOT of things during intern year. And the only way that happens is by having a lot of face/hospital time. This is of course not as first hand knowledge. But as a nurse and residents have told me so.

Also, let's be honest, or wait, let's not. Because you KNOW that the residencies/program directors/residents-who-are-intimidated-into-doing-so and others involved in residencies that really just need to bring more residents on board, that already lie about their hours will just continue to do so and not fall within the hour limits.

And, as I've learned, it takes Alot for a program to lose it's accredidation for violation of hours. What ends up happening is that the attendings/program director/etc. at programs that are always over the 80 hour work week limit come down hard on the residents for going over hours and blame the residents for the problem! So then the residents fudge the numbers on their time cards so they don't get cracked down on.

To Camilla, they're only counting the "Time spent in the hospital by residents on at-home call." Not the whole home call.; November 3, 2010 at 9:22 PM
Cheri said...: I have read what some of you have said in regards to keeping the ridiculous LONG hours of residencies, especially PGY1 hours. I understand your points, but totally disagree with not supporting this needed change. In fact, I think there should be a lot more change in the hours. People are people at the end of the day. Doctors are people at the end of the day. Doctors have lives outside of the hospital at the end of the day. May doctors have wives, kids, and families at the end of the day and should be able to have somewhat of a life during residency.

Also, have we ever asked ourselves the question of what are these residents really learning after being on call, or working for a ridiculous amount of hours????? Have we asked ourselves what are these residents doing to the patients when they are anything but there during the end of their shifts that last longer than an earth day? Speaking personally, my grandfather died because a resident was not watching him closely and we found out later he was on one of those ridiculously long shifts and probably was not all mentally "there" and did not attend to my grandfather despite all the complaints by my grandmother about the status of my grandfather.

These regulations are needed for the residents and also for the patients. Safety is MUCH more important than learning! Safety allows many more people to live...including residents. Have you people ever worried about yor resident getting in an accident because he/she is SO tired after a shift?

Here are some great examples of what my husband and some of my friends have reported doing after a LONG shift:

1. Looking for the soda where the dishes are kept.
2. Claiming he couldn't turn at a T-intersection
3. Taking a shower after his shift and not turning off the water afterwards.
4. Trying to put his pants on like a shirt.
5. Taking out the trash to the bathroom instead of the dumpster.

These are only SOME of the strange things people do without sleep. We need to ask ourselves, if residents are doing weird things like mentioned above, then what are they doing to patients?????

Considering the amount of MENTAL energy it takes to be a doctor and considering the amount of RISK involved with treating patients (especially surgery) it only makes sense to have residents get...wait for it...sleep!!!!!

What makes this new ruling so interesting is that residency programs will simply figure out a way to get around certain things and make life continue to be unbearable for people.

Just remember, a med student doesn't turn into a super hero when he/she enters into residency. Every resident is a human and needs sleep, and for that matter food (my husbands residency program JUST enacted a 10 min. lunch break!) We as a society need to support that and enact more and more and more laws until it is done.

If these residency program can figure out how to get passed the system with these new hours, and we all know they will, then they can figure out how to make the new regs. work without increasing residency times.; November 3, 2010 at 9:25 PM
Unknown said...: I honestly would like to see how the programs are going to implement these regulation.
The amount of "illegal" scheduling and things that go on in programs is already SO hard to manage, that I can't see how the programs are suddenly going to be able to implement these new "rules". It will be interesting.; November 3, 2010 at 10:30 PM
Unknown said...: And Cheri - I agree with you 110%; November 3, 2010 at 10:31 PM
Colleen said...: Cheri - I agree with you! Safety for patients is most important, and I, too, have seen my MSIV husband come home from long shifts completely addled and do silly things. I worry all the time that he won't make it home as he is prone to falling asleep at the wheel.; November 3, 2010 at 10:43 PM
Melisa said...: I don't comprehend all of the ramifications, but I'm glad they are limiting the hours. I think it is crazy what they expect the residents to endure. If they can't learn it in an 80 hour work week (averaged over the month) then maybe they should add another year. Just because doctors in the past have endured this, doesn't make it right nor does it make us wimps. Maybe it makes us better informed on the benefits of a decent night sleep for people operating inside another human being. Personally, I would rather have more time with my husband over a 6 yr residency than no time with him during a 5.; November 3, 2010 at 10:56 PM
Anonymous said...: Hi all! I've never written on here before but read from time to time and have finally decided I want to be more involved...hope that's okay! As for this particular post and these new regulations I just have a few thoughts--I agree that I'd like my husband to have more family time than what it probably considered "typical" in residency programs. And in fact, I think he already does! If I understand it correctly, his program already counts moonlighting as part of the 80 hours max--but as a PGY1 we haven't dealt with that personally yet. And since his program allows quite a bit of at-home call, he is able to see us more than I thought he would. However, it sounds like that will probably change some due to the rule of at-home call also counting as part of the 80 hours. He is part of a small residency program so like pp mentioned..how will they have enough docs to cover all the needed call with these rules? Hmmm. Also, as a former nurse I know that working anything past 12 hours was tough for me...I would have never survived 30! Eek!; November 3, 2010 at 11:35 PM
Mrs. Dawkter said...: I wonder how the will implement these new rules when many programs are not able to follow the current rules. And its not a matter of programs being cruel or taking advantage of residents but more a limit of resources. In order to comply with these standards many programs would need to DOUBLE the amount of residents they have, and although they are requesting additional residents it doesn't mean they are given the spots.

Unfortunately I don't think passing new rules are going to help with hours at all.; November 4, 2010 at 12:03 AM
Amanda E. said...: I completely see both sides of this argument. On the one hand, I absolutely HATE when government gets involved in matters that they know absolutely nothing about (example: San Francisco banning Happy Meal toys if you choose to purchase a meal that doesn't meet their stated nutritional values). I am sure hospitals will be short staffed which does nothing for patient care and creates longer lines/wait times. My husband is also worried that residents will no longer be able to have more than 1 day off in a row (thus taking spontaneous short trips as a family may be a thing of the past). Another issue is the length of residency programs - I, too, think that the entire process is long enough without adding years due to restricted hours.

On the other hand I am saying "if you are going to be short staffed, hire more residents." Yes, I realize this is a $$ issue, but residencies are government sponsored for the most part. If the government is willing to go changing rules and making regulations, they should have funding to back that up (in the form of more spots to fill in programs). I am also scared to death my husband will fall asleep at the wheel driving back home from a long shift...too many times I have heard about hideous accidents occurring involving residents operating on entirely too few hours of sleep. Just as residents are a resource to the hospital, sleep is a resource to our residents...who are humans, btw. DH does the most ridiculous things when he is overtired---although he will make an excellent doctor, I, myself, would NEVER want him treating me as a patient if he hadn't had a solid night's sleep (which for him is a minimum of about 6 hours). There is also a financial cost to the hospital for resident mistakes...our society is so litigious and becomes more and more so with each passing day.

Again, I'm in the middle on this one...either way I think we are screwed. (I know I know, I'm being a negative Nancy on this one).; November 4, 2010 at 8:13 AM
Anonymous said...: Thank you Jaidi, I had no idea about these changes.

As awesome as it would be to go back to the days of literal, live-in "hospital residents" who aren't allowed the distractions of wives and children, in modern times of work-life balance, we need some kind of regulation.

Besides that, residents have more to learn, more expectations (yet less respect) from patients, and larger patient workloads than ever before. Studies show that old timers who are so judgmental about current duty hours got far more sleep and had far less stress while at work than our DHs.

That said, I agree that the 16 hour shift restriction seems kind of funky.

Also, is the ACGME government? I thought it was private.; November 4, 2010 at 1:54 PM
Palmacho 7 said...: Hello, I have never posted here, but my husband is a PGY4. His program doesn't allow moonlighting, so that's not an issue. He has some rotations where he averages over 100 hours a week, some where the average is around 60. He always lists the same hours because he got sick of keeping track during the intern year. Last year one of his colleagues listed a violation to the hours and that colleague was told that by complaining to the upper ups, the entire program could be jeopardized so doctors need to bring hour violations straight to program directors before putting anything in writing. Or else...

I think it won't make any difference. There are always loopholes. My favorite- the *direct patient care* loophole. They don't spend that many hours in *direct patient care* because charting, for instance, is not *direct patient care*.

These new regulations are just new regulations. Will not change a thing, and if your doctor wants to fight for his rights to fewer hours, watch out because the PROGRAM you are in may get penalized...; November 4, 2010 at 4:35 PM
Anonymous said...: I just had a chat with my husband, a MS4, about this post and the comments above.

He would first like me to point out that the GOVERNMENT did not put these restrictions in place. ACGME is a PRIVATE, non-profit council that evaluates and accredits medical residency programs in the US. Therefore, those above who are upset about the government getting involved- you can relax- this isn't the government. He (my husband) was split in his personal opinion of the new regulations. The overall reduction of hours is good (if anyone could ever stick to it), but he does agree that interns not getting the experience of "call" nights, and having to go through some of the things that you get to see/do during those longer hours is a downfall. On the flip side? Exhausted residents are ineffective residents. All in all? The changes are probably a good thing (again, if anyone sticks to them).

All that being said, he and I have a very different perspective. He is in the military, meaning we will enter a military residency program next summer. The military functions off a similar, but different set of standards. The first being, ALL soldiers- including medical residents/interns- must be combat ready at all times. This means there is a mandated 24 hour off period for each week worked. The 80 hour regulation is also kept more rigidly (though husband admits that the surgical interns frequently fib about their hours- BUT these interns/residents are CHOOSING to work longer than 80 hours. When/if their superiors- aka: Commanders, aka: attendings- find out they've worked over 80 hrs, they're reprimanded. Husband just told me about the PGY2 on his service- ortho- who reported 110 hours last week. The PGY2 was questioned by his superior as to why he didn't go home or say something. The resident felt it was his duty to just keep working. Superior was NOT pleased.) As military residents they are also not allowed to moonlight EVER, regardless of their year in residency.

Military medical students/residents function with more rigidly defined hours and duty regulations that are actually fairly similar to those just put in place, and I/my husband can assure you they are not robbed of any learning opportunities afforded by ridiculously long hours. As I said, these civilian standards don't apply to us, but as an outsider who used to be treated by civilians? I wouldn't want an overworked resident treating me. Just my opinion.; November 7, 2010 at 9:14 PM
Camilla Millar said...: Yes, all of our hubby's can attest to doing some crazy things post-call, but I read a study a few years ago in JAMA (you'd have to look it up I don't have the link)evaluating patient mortality rates before and after the hour-restrictions and there was no significant change for the better.

Any quick search using the key words patient outcomes, JAMA, and duty hour restrictions will make it clear that there are definite positives AND negatives to changes in duty hours. In one study, key clinical faculty believe that duty hourlimitations have adversely affected important aspects
of residents’ patient care, education, and professionalism,
as well as faculty workload and satisfaction. Since my hubby is a surgical resident, the data shows that residents are now performing 20% less cases in the OR. Although you may not want to be treated by an overworked resident, you may also be in as mujch danger of poor decision making by your surgeon who has just graduated from residency. It is important to realize duty hour-restrictions may have consequences down the road which are hard to gauge now.

What is clear in most studies is that residents report a better social and family life. Also, a few studies show that resident burnout is going down. This is great news for us as emotional caretakers of our DrH's!

I just think it is very important to realize that great patient care and education somtimes means a long night or a long week for our hubbies.

We need to be aware that if we wanted our husbands/wives to be on a standard work week, medicine was not the field for them. Crazy/weird shiftwork is a hard part about medicine. There are great things about it too. Financiallly, there will eventually be security. It is unlikely your husband will ever be 'layed off.' And most importantly, if your husband is gone, isn't it comforting to know they're expertise and sacrifice means someone else is lifted up during a really bad day?

P.S. ACGME has been under OSHA's radar (a government agency) recently. . . . . just sayin'.; November 11, 2010 at 12:39 AM

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Tuesday, November 2, 2010

Residency Duty Hour Changes

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