The Accreditation Council for Graduate Medical Education has revisited its standards for resident duty hours and determined that some modifications should be made, mostly for first-year residents. All other residents should still be subject to an 80-hour work week and up to 24 hours of continuous duty, according to an article published online in the New England Journal of Medicine.
The 16-member ACGME task force that wrote the standards will review public comments and make modifications before July 2011, when the new standards will go into effect. The original 2003 standards have been the subject of much consternation in the medical community, with opinions differing over whether they have been too restrictive or too loose to properly protect patients and ensure a good quality of life for residents.
According to the latest report, the 2003 standards had the following three “problematic” elements, as identified by the educational community and the public:
▸ The limits on duty hours may have created a “shift mentality” among residents.
▸ Many academic programs began focusing on meeting the duty hour restrictions, perhaps at the expense of education.
▸ The 80-hour work week, with up to 24 hours of continuous duty, was seen by many as compromising patient safety.
In 2008, the Institute of Medicine took a hard look at the ACGME standards and, among other things, recommended that no residents should exceed 16 hours of continuous duty.
The ACGME task force considered ways to reconcile the IOM's suggestion for an across-the-board restriction on duty hours vs. the continuing plea from academic programs that duty hours needed to be tailored to each specialty (N. Engl. J. Med. 2010 [doi:10.1056/NEJMsb1005800]). For surgery, in particular, it would be difficult — and contrary to learning — to have a resident leave in the midst of a procedure because his or her duty hours had been reached. The ACGME panel also had to weigh whether there was sufficient evidence to show that working more than 16 hours or up to 30 hours continuously led to more medical errors.
According to the ACGME panel, the data thus far indicate only that first-year residents are more prone to mistakes as a result of sleep deprivation. Therefore, the task force urged a new paradigm, whereby first-year residents cannot be on duty for longer than 16 hours continuously and should have 10 hours off and 8 hours free of duty between their scheduled duty periods. First-year residents are not allowed to moonlight, and they must have direct, in-house, attending-level supervision. All residents are allowed to work up to an additional 4 hours to facilitate patient handoffs — an area of concern for patient safety.
The panel decided not to tailor duty hours to specialties “because studies have not shown that the safety effect of current standards varies with specialty,” said the authors.
The IOM had also criticized the ACGME for not properly enforcing the duty hours. The ACGME is now undertaking annual site visits and analyzing whether institutions can comply. Eventually, the organization will give each institution a report on its compliance status and recommendations for resolving problems. The reports will be made available to the public, said the authors.
Wake Up Doctor, a coalition of public interest and patient safety groups, gave the ACGME “Fs” for failing to comply with the IOM recommendation that continuous duty be restricted to 16 hours for all residents and for failing to better monitor compliance with the standards. However, the recommendation for greater supervision of first-year residents got higher marks.
“I think the acid test will be in the details,” said Helen Haskell, founder of Mothers Against Medical Error and a coalition member, in a statement.