In 2003, the Accreditation Council for Graduate Medical Education (ACGME) released its first regulations on work hours and supervision for residents. However, with these first regulations came much debate on how effectively duty hour limitations were at achieving the intended goals of improved patient safety as well as enhanced resident education. In 2011, the ACGME increased these regulations, a change that dramatically shifted traditional 24-hour in-house call schedules for many programs across the United States. The newest regulations require that interns have direct supervision from more senior residents or attending physicians at all times. The 2011 standards also limit first-year resident duty periods to a maximum of 16 hours and have a stricter 24-hour limitation for senior residents.
“With the most recent ACGME duty hour regulations, the professional development of residents and the quality of their education has come into question,” explains Brian C. Drolet, MD. “The regulations inevitably lead to more frequent patient handoffs and less continuity of care.” Although fatigue can be an issue for patient safety, there is also evidence that frequent transfers of care and miscommunication can lead to errors.
Surveying Views of Surgery Residents
Previous studies have suggested that surgical residents believe some level of duty hour restriction is warranted, but they do not support significant regulation of duty hours. More recently, Dr. Drolet and colleagues had a study published in JAMA Surgery that examined surgical residents’ views of the ACGME requirements after they were implemented in 2011. The study assessed the perceived effects of the regulations on patient care, resident education, and quality of life. It also evaluated self-reported compliance and duty hour falsification rates from surgical residents.
For the study, a 20-question electronic survey was administered to more than 6,000 surgical residents at ACGME-accredited teaching hospitals throughout the United States 6 months after implementation of the 2011 ACGME regulations. About two of every three surgical residents reported that they disapproved the requirements (Table 1). Most respondents indicated that education, preparation for senior roles, and work schedules were worse after the 2011 regulations were implemented. A majority also reported no changes in supervision, safety of patient care, or amount of rest.
In addition, the study by Dr. Drolet and colleagues found that quality of life was perceived to be better for interns, but most residents believed that it was worse for senior residents. More than two-thirds of respondents also reported dealing with more patient handoffs and a shift of junior-level responsibilities to senior residents. Furthermore, many residents reported noncompliance and duty hour falsification (Table 2). “Overall, surgical residents reported that the intended improvements in patient safety, resident quality of life, and education have not been borne out after implementation of the ACGME changes,” says Dr. Drolet. “It may be difficult for surgical residents to learn and care for patients under the 2011 ACGME regulations.”
Considering a New Model
Based on results of the study, Dr. Drolet and colleagues noted that a new model for duty hour regulations may be better for both patients and residents. “One of the major issues raised in our study was continuity of care,” Dr. Drolet says. “Regulating work hours into shifts and increasing the frequency of patient handoffs can diminish continuity of care. To improve patient care while maintaining resident quality of life and education, it’s important to improve patient handoffs and ensure appropriate supervision with graduated responsibility.”
Adequate supervision of physician trainees is necessary, according to Dr. Drolet, and efforts to mitigate fatigue are equally important. “However,” he says, “gaining independence and learning to function while providing prolonged, focused patient care are vital components of graduate medical education, especially for surgeons. During training, surgical residents should learn to deal with and recognize fatigue. It should be noted that there has been public concern about tired residents making critical decisions, but this is more often a problem of image than reality. The frequency of adverse patient events has never been directly linked with fatigue.”
Dr. Drolet says that a new paradigm of work-hour regulations should be considered. “There needs to be greater flexibility, fewer transfers of care to promote continuity, and a stronger focus on graduated responsibility,” he says. “We should impose reasonable limits on shifts and total hours. Junior residents should have greater levels of responsibility with decreasing shift regulations throughout the intern year. They also need appropriate supervision. Perhaps most important is ensuring that these trainees have mentors who are appropriately selected by program directors and senior residents. The primary goal during training needs to be preparing residents adequately for their transition to the independent practice of surgery.”
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