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Accrediting counsel to set resident duty hours by Dick Peterson Public Relations All that dust kicked up these days over resident duty hours should settle after a June meeting of the Accreditation Council for Graduate Medical Education. At least that’s the prediction from MUSC otolaryngologist J. David Osguthorpe, M.D. As chair of the ACGME’s Residency Review Committee (RRC) for otolaryngology, Osguthorpe will meet along with the members of the council’s 28 RRCs and their subspecialities to set a duty hours standard for residents in accredited graduate medical specialty programs nationwide. He expects the meeting to take the character of a sequestered jury. “We’ve been told we will come up with a decision, and we will stay there until we do,” Osguthorpe said. In his opinion, an ACGME standard for resident duty hours is a far better solution to the apparent inequities and isolated cases of resident abuse than could be set by state or even federal law. “There’s a problem with a legislative mandate,” Osguthorpe said. “It doesn’t place sufficient emphasis on resident education, and, per usual, it’s an unfunded mandate.” From a time when federal funding for graduate medical education was at 12.8 percent of Medicare reimbursements to teaching hospitals to today’s level of less than 6 percent, it has become apparent that federal support will continue to wane. In fact nothing about the education of physicians seems to be a priority in state or federal legislation. An unfunded mandate is more than likely an unenforced mandate, Osguthorpe said. Federal agencies are neither equipped nor funded to enforce federally mandated standards.  The physician-run ACGME, however, governs residency programs in the United States through peer-review enforcement of curriculum standards and accredits programs on one- to five-year increments. Its accreditation, which is awarded, modified or withdrawn based on its reviews, serves as a guide to medical school graduates applying for quality residency programs. At the meeting in June, Osguthorpe expects the standard on duty hours to be based on already established guidelines that include one day off per week unmolested (no on-call) and no more than every third night on call, in house. Heretofore the only specific duty hours required by the ACGME has been for emergency medicine residents. For the rest, the ACGME has left the weighing of time for patient care against medical education up to the individual specialty program as long as teaching staff are readily available. “Residents should not be used solely for service needs—starting IVs, doing EKG’s—and should be provided adequate sleeping and food services,” Osguthorpe said. Beyond that, duty hours and on-call time periods must not be “excessive,” according to ACGME guidelines. The purpose of a graduate medical program is education, not cheap labor. In 1999, 19.5 percent of the residency programs surveyed by the ACGME had potential problems with duty hours, Osguthorpe said. When review committees examined the problems and provided instructional materials urging programs to “pay more attention to duty hours,” complaints dropped to 8 percent and in otolaryngology, with which Osguthorpe is most familiar,  to 3 percent. Most complaints to the ACGME come from residents in general surgery, pediatric surgery, neurosurgery and from some internal medicine subspecialities, he said. And complaints about resident duty hours are almost never isolated. Osguthorpe said they are usually accompanied by other serious problems in a residency program.  Medical education competencies increasing Time was, competency in patient care and medical knowledge was about all a medical resident had to concentrate on. It was enough. It kept the initiate’s focus on medicine and off distractions like sleep, food and recreation. But maybe it’s not enough. The Accreditation Council for Graduate Medical Education has added four general competencies to the original two as a “... first step in a long-term effort designed to emphasize educational outcome assessment in residency programs and in the accreditation process,” according to council literature. During the next several years, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice will be incorporated into ACGME’s Residency Review and Institutional Review committees’ requirements. As chair of the Residency Review Committee for otolaryngology, Osguthorpe, is closer than most to planned curriculum changes for residents, the thinking behind them, and how they will be implemented and reviewed for accreditation in residency programs throughout the country. “These additional competencies will become reality as residency programs incorporate them from within the next two to three years,” Osguthorpe said. “Many institutions are putting together courses on ethics, for example, to be taken by all residents. Others are offered by the educational arms of specialty societies who put together modules that are specialty-specific and often Web-based. Indeed, such is being done by the American Academy of Otolaryngology-Head and Neck Surgery (about 12,000 members), of which Osguthorpe is the coordinator for education.  “It sure helps that I know, as the RRC chair, exactly what the new requirements will be, and in what time line for implementation, so I can then ensure that such is available to residents and program directors from one of the nine AAO-HNS education subcommittees that report to me,” Osguthorpe said. “Primary care residency programs and national societies are ahead of the other specialties, but, fortunately, they have been very willing to share what they have developed” Osguthorpe said, adding that the efforts to comply with ACGME requirements will come from within each institution and each residency program. The residency program must require its residents to develop the competencies in the six areas below to the level expected of a new practitioner. Toward this end, programs must define the specific knowledge, skills, and attitudes required and provide educational experiences as needed in order for their residents to demonstrate the competencies. Patient care Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to: communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families  gather essential and accurate information about their patients  make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment develop and carry out patient management plans  counsel and educate patients and their families  use information technology to support patient care decisions and patient education perform competently all medical and invasive procedures considered essential for the area of practice  provide health care services aimed at preventing health problems or maintaining health work with health care professionals, including those from other disciplines, to provide patient-focused care. Medical knowledge  Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Residents are expected to: demonstrate an investigatory and analytic thinking approach to clinical situations  know and apply the basic and clinically supportive sciences which are appropriate to their discipline. Practice-based learning and improvement Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to: analyze practice experience and perform practice-based improvement activities using a systematic methodology locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems  obtain and use information about their own population of patients and the larger population from which their patients are drawn  apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness  use information technology to manage information, access online medical information; and support their own education  facilitate the learning of students and other health care professionals.  Interpersonal and communication skills  Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Residents are expected to: create and sustain a therapeutic and ethically sound relationship with patients  use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills  work effectively with others as a member or leader of a health care team or other professional group  Professionalism  Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to: demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development  demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices  demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities  Systems-based practice Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to: understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources practice cost-effective health care and resource allocation that does not compromise quality of care advocate for quality patient care and assist patients in dealing with system complexities  know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance.