Wednesday, July 02, 2003

Yesterday the Accrediation Council for Graduate Medical Education's (ACGME) resident work hour limits went into effect. The goal of these, according to the ACGME is to prevent sleep-deprived residents from harming patients. The limits are:
1. Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities.
2. Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities.
3. Adequate time for rest and personal activities must be provided. This should consist of a 10 hour time period provided between all daily duty periods and after in-house call.
There are more rules regarding on call duty:
1. In-house call must occur no more frequently than every third night, averaged over a four-week period
2. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care as defined in Specialty and Subspecialty Program Requirements.
(from the ACGME www.acgme.org)
While call from home does not count in the 1-in-3 limits, each resident must be given 1 day in seven out of the hospital with no clinical or didactic responsibilities. And if the resident is called in, the 80 hour clock starts ticking. An exemption for an additional eight hours of time may be submitted but it requires a great deal of paperwork and effort.
One of the objections to this is the effect it will have on continuity of care. DB posted about this yesterday (www.medrants.com/archives/001811.html)There is a great deal of information that can be lost during the "hand-off" of a patient. The medicine program where I trained had a "float" system, and it worked pretty well, but I am sure that there will be some growing pains. However there are some special problems that surgical programs face:
THE "FLOAT" CALL SYSTEM: People prefer to work during daylight hours. That is why elective cases such as hernia repairs and cholecystectomies are done during the day. Night for the surgeon usually means trauma care and emergencies such as appendectomies and bowel perforations. Nowadays most trauma is non-operative (depending of blunt v/s penetrating ratio) rather than operative. The float resident then not only misses the elective cases during the day but stays up all night with trauma patients that don't provide any operative experience.
THE NUMBERS GAME: On average a surgical residency consists of five years of clinical work with some programs requiring or allowing time for research. During that time the resident must obtain sufficient operative experience in a wide variety of procedures. If one's hours are restricted then case numbers could suffer. There is a grain of truth to the adage "The only problem with being on call every other night is you miss half the cases"
THE FUMBLE: The possibility of disaster in a "hand-off" of a surgical patient can be much higher than in a medical patient. Serial examinations of a patient by a surgeon is an invaulable tool in the assesment of a surgical patient. When the first examiner signs off, subtle signs may be missed.
THE REAL WORLD: I am a surgeon in private practice and even witout all the "scut work" associated with a residency, I work about 65 hours a week. And this is in a six man practice. Will the hour-limited resident be able to function?
As opposed to earlier efforts to control works hours, this isn't being treated with a wink and a nod by program directors.
They know the ACGME is serious and will lay down the law, as they have done with some programs (ex. Yale). I feel that in a few years residencies will become longer to allow for caseloads to be adequate. Tomorrow I'll post on some resident opinions of work hours.
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