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GME addresses resident duty hours, changes to core standards by Cindy Abole Public Relations In an effort to improve care and patient safety, the health care industry is undergoing major changes in order to enhance the quality of resident education as well as their quality of life. Newer standards proposed by the American Association of Medical Colleges (AAMC) and the Accreditation Council for Graduate Medical Education (ACGME) will help influence residency education by examining training programs and methods, plus re-establish priorities among the country’s accredited academic medical centers.  MUSC now joins the ranks of 125 medical schools and more than 3,500 hospitals with resident physician training programs across the country that are scrambling to integrate the new ACGME requirements. By July 1, all ACGME-accredited hospitals and institutions must comply with these new standards. Guiding this effort locally is MUSC’s Office of Graduate Medical Education led by George Arana, M.D., senior associate dean for GME and Franklin Medio, Ph.D., associate dean for GME.  John Heffner, M.D., medical director of the medical center, heads a task force developing MUHA policies. All have teamed with the College of Medicine and MUSC Medical Center administration and staff  to create  a GME Task Force composed of physicians, residents, hospital administrators, department chairs, pharmacists, nurses, medical industry representatives and community practitioners — individuals eager to take a proactive stance in supporting MUSC residency education. The task force group gathered for a kick-off meeting on Feb. 1 at Gazes Auditorium.  “Every medical institution with a residency program is facing these same changes,” said Medio, who besides managing aspects of residency education serves as one of seven representatives on the AAMC’s Group On Residency Affairs National Steering Committee. “Currently, there are no educational models that have adopted these changes, making it a challenging effort for everyone involved.” Timeline for change  Under the leadership of Arana and the GME office, the group has established a timeline for the task force to evaluate issues and set priorities in  creating a strategic plan to incorporate these changes. The task force will be comprised of four work teams that will address the following ACGME-recommended areas: ACGME’s six general competencies; faculty supervision and development; resident duty hours; and GME funding as it relates to the College of Medicine and other clinical facilities. “Although resident work hours has been hotly debated in other parts of the country for more than 15 years, it has not risen to national attention until a 1999 study by the Institute of Medicine (IOM) reported that there was a lack of patient safety policies and procedures in American hospitals, particularly those engaged in teaching medical students and residents,” said Arana. “The IOM report suggested that unnecessary morbidity and mortality may be due to elements present in the medical teaching environment. Further reports questioned whether these patient safety problems may be related to fatigue and weariness secondary to sleep-deprivation that followed from excessive work hours of resident physicians, some working as many as 100-140 hours weekly.” In July 2001, the ACGME which is responsible for accrediting every residency program in the U.S., accepted the results from a “program work group” which set the stage for major and comprehensive revisions in regulations governing both the education of residents as well as the health and well-being of these student physicians. The educational revisions were focused on the evaluation of resident performance along with six specific competency areas: patient care; medical knowledge; practice-based learning and improvement; interpersonal and written communica-tion skills; professionalism and systems-based practice. Resident duty hour standards The revisions instituted by the ACGME for the “health and well-being of resident physicians” are the most controversial and complicated and are termed Resident Duty Hour Standards. These standards dictate that resident physicians are limited to an average of 80-hours-per-week in the hospital and other clinical educational areas. Starting July 1, all residency programs will be held to an 80-hour-per-week limit and no more than 24-consecutive hours of clinical responsibilities for the time the resident is in the clinical educational environment. Each specialty and subspecialty program will be responsible for incorporating these changes while maintaining the other educational and professional standards for accreditation. These changes in residency education have been echoed by the clinical and hospital regulators, JCAHO, who have followed suit by adjusting their regulations. As of Jan. 1, JCAHO established new guidelines that promote quality care and patient safety through complete education and training of staff.  “JCAHO and ACGME standards require documentation of competency for house staff,” said Heffner who is also a  GME Task Force group leader on the resident duty hours issue. “It’s a standard that requires program directors of training programs to document the competencies for certain procedures and patient care functions performed by trainees. In documenting these competencies, we as a health care provider, have the reassurance that the resident physician who is called to do a procedure for a patient would have acquired and demonstrated proficient skills to conduct the procedure safely.” Each specialty and subspecialty program will be responsible for incorporating these changes into their program while maintaining other standards for accreditation. Other requirements include changes to internal review documents and evaluations handled by the Internal Residency Review Committee. Failure to comply will result in citations to the program and threaten its chances for reaccreditation with ACGME. At MUSC, some 500 physician residents and fellows are enrolled in approximately 45 residency programs. Some will be more directly affected by the proposed standards than others. Various surgical programs that have been highly-impacted by the resident duty hours regulation include general surgery, orthopaedics, neurosurgery and OB/GYN who have already started to plan in order to be in compliance with the 80-hour-per- week proposed standard by July 1 when the rule goes into effect. More specialized programs like radiology, urology, psychiatry and pediatrics will have less effect.  Value of technology In order to assist all residency programs, the GME office and the university hospital have planned to develop a system that would simplify documentation and management of all teaching, didactic, clinical and research activities for each resident. This will be accomplished with a computerized, data management system presently being piloted by several programs including surgery, psychiatry, OB-GYN and hematology/oncology. The E-Value pilot system is coordinated under the direction of Larry Afrin, M.D., Hollings Cancer Center director of information technology. When completed, this new web-based system will provide GME participants with paperless evaluations and manage an enormous amount of information and data for all GME programs.  Under the new policy, departments will require restructuring with rotations, lecture schedules, etc., while being stretched financially as they hire additional staff to make-up for the work and duties formerly performed by physicians-in-training.  “It’s hard to work only on one area like duty hours without addressing changes in other areas such as competencies and supervision,” Medio said. “It’s all very interrelated and inseparable. You can’t talk about one area without addressing the others. Ultimately, all this work will impact on the funding of GME.” Financial impact The financial impact for integrating these changes in graduate medical education worries practitioners and leaders on all levels. Results from the 1997 Balanced Budget Act have already cut federal funding for graduate medical education by almost $2 billion forcing programs to reassess themselves while maintaining a quality program within a safe and supportive learning environment.  But GME supporters have a more positive outlook.  “With the guidance and cooperation of MUSC leadership, staff and practitioners, the chances for success is good,” Arana said. “The College of Medicine and medical center have tackled similar challenges in the past and have forged one of the best GME programs in the country, frequently cited as the ‘pacesetter’ in various aspects of resident education.” “We’ve got a great group of progressive directors and hospital leaders combined with a good track record for GME,” Medio said, referring to MUSC being one of the first institutions to develop their core curriculum and integrate a 360-degree evaluation process to assess professionalism in residency education. “This GME Task Force is an important group of key people who will act in a consensus-building role. We hope to carry this positive, cooperative thinking forward and create our strategic plan.” “The key individuals who are responsible for physician education and patient care are coming together in a group process to identify what resources we will need to meet the new standards,” Heffner said. “We will  prepare the best strategy to maintain, first and foremost, excellence in patient care while continuing to offer excellence in resident physician education. We anticipate that we’ll exercise our habit of turning challenges and problems into opportunities to further refine the programs that we run.” In the course of the next six months, GME Task Force groups will continue to meet independently to discuss the proposals and make recommendations to help draft the strategic plan. A review of the plan by the GME committee will be finalized by June and will be presented to MUSC’s Board of Trustees. “Our plan is to have a final document confirmed by June and ready for implementation to meet the July 1 deadline,” said Arana. Members of GME Task Force Working Teams ACGME Six General Competencies Leader: John Feussner. Facilitator: Larry Afrin; Thad Bell, Eugene Brown, Paul Bush, David Lewin, Michael Jernigan, George Johnson, Patrick O’Neill, and Gregg Smythe Faculty Supervision, Faculty Development Leader: Flo Hutchison. Facilitator: Ben Clyburn; Meghan Baker, Amy Blue, Joan Herbert, Paul Lambert, Carl Mazzola, Larry Raney, Michael Southgate, and Colleen Thomas Resident Duty Hours Leader: John Heffner. Facilitator: Ben Weinstein; Kathryn Miller Arababi, Debbie Blevins, Tom Brothers, Harry Clarke, John Glaser, David Osguthorpe, Steve Schabel, and Lucy Yarborough Funding of Graduate Medical Education Impact on the COM, MUSC Clinical Facilities Leader: Bruce Elliott. Facilitator:Lisa Montgomery; John Cooper, Alexander Ellis, Stephen Haines, Mark Lyles, John Oldham, David Parker, Pam Verdery, and Karen Weaver   Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, catalyst@musc.edu. Editorial copy can be submitted to Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to petersnd@musc.edu or catalyst@musc.edu. To place an ad in The Catalyst hardcopy, call Community Press at 849-1778.