First-year residents will once again be permitted to work up to 24 consecutive hours following a reversal of a rule implemented in 2011 that restricted them to 16 hours, the Accreditation Council for Graduate Medical Education (ACGME) announced.
According to a memo issued by the ACGME March 10, 2017, the change reverting back to the 24-hour ceiling was evidence based.
“The preponderance of the evidence from a number of studies conducted after the current 16-hour cap was implemented in 2011 suggests that it may not have had an incremental benefit in patient safety, and that there might be significant negative impacts to the quality of physician education and professional development,” the memo states. The work week is still capped at 80 hours worked per week, with 1 day free from clinical experience or education in 7, and in-house call no more frequent than every third night.
An ACGME task force determined “that the hypothesized benefits associated with the changes made to first-year resident scheduled hours in 2011 have not been realized, and the disruption of team-based care and supervisory systems has had a significant negative impact on the professional education of the first-year resident, and the effectiveness of care delivery of the team as a whole.”
Dr. Sharmila Dissanaike
Sharmila Dissanaike, MD, FACS, chair and professor of surgery at Texas Tech University, Lubbock, said in an interview that the change back to a 24-hour ceiling provides “an increased flexibility for all residents in order to allow completion of immediate patient care responsibilities, such as finishing an operation, and ensure smooth handoffs. Both of these should improve work flow for both trainees and supervisors.”
Mark A. Malangoni, MD, FACS, associate executive director of the American Board of Surgery, said he believes the change back to 24 hours is a positive thing.
Dr. Mark A. Malangoni
“The 16-hour requirement posed a lot of scheduling problems,” he said in an interview. “In essence, what it meant was you had residents that either couldn’t take call or they did take call, it was very limited in what they could do.”
Complicating the issue of time is the nature of what needs to be taught to residents.
“What has definitely changed is the breadth of knowledge and repertoire of technical skills that must be learned by today’s residents,” Dr. Dissanaike said. “As scientific knowledge and technical capabilities expand, there is ever more to learn and increasingly less time in which to learn it.”
Dr. Malangoni added that the time restraints didn’t allow for residents to see the natural progression of the patient’s condition. “You don’t have the chance to continue to assess that over a longer period of time,” he said. “That is really important in learning when to operate on someone, but also when not to operate on someone because they will get better without an operation.”
Compounding that is a greater need for reporting to meet regulatory requirements.
“Concurrently, we have increased requirements for documentation and clerical tasks, and reduced time available to do it,” Dr. Dissanaike continued. “All of this has led to a severe ‘work-compression’ for the modern resident, and I suspect the high rates of burnout and depression that are being reported in many specialties are at least partly a result of this phenomenon.”
That being said, Dr. Dissanaike was quick to add that this latest change should not be considered a “final solution” and that there are “many ongoing issues around resident fatigue, as well as adequacy of educational experience that still need to be addressed.”
Dr. Malangoni added that residents need to be more mindful and take more responsibility for their own health and well-being.
“I think what residents need to understand is they are really in charge of their own well-being. Making that point is really a key,” he said. “So it’s not only what you do while you are in the hospital, but you are also responsible for what you do when you are not in the hospital. ACGME cannot regulate what people do in their free time. If you work a 24-hour shift and you decide you are not going to sleep the next day for whatever reason, your well-being is likely not going to be what you want it to be and what, I think, your patients want it to be.”