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Duty hour limits affect residency education, patient care by Cindy Abole Public Relations On July 1, resident physician training programs at MUSC and at more than 1,500 hospitals across the country faced new “duty hours” standards designed to relieve resident fatigue, improve patient care and ensure patient safety. At issue is the recognition and acceptance of new standards established by the Accreditation Council for Graduate Medical Education (ACGME) regarding the time residents spend in patient care duties and other activities related to their program. The minimum standards on resident “duty hours apply to ACGME—accredited residency programs in all 118 specialties and sub-specialties. To accomplish this, MUSC’s GME Office has proactively convened with a team of hospital leaders, educators and clinicians to formulate goals and objectives to ensure compliance with these new regulations. The new provisions were established to improve the quality of resident education by regulating “duty hours” in order to minimize resident fatigue. On the MUSC campus, the standards affect 45 residency programs and its 500 residents.  Currently, programs allow residents the following: one 24-hour day off every seven days; on-call no more than one night in three; and no more than 80 total hours per week averaged during a four-week period.  “The new changes encourage all of us in residency education to focus on the resident’s role in hospitals and clinics,” said Franklin Medio, Ph.D., associate dean for graduate medical education. “It offers an opportunity for the hospital and the College of Medicine to collaborate on new ways to improve patient care and residency education.” To that end, the GME office established a GME Task Force charged with the purpose of developing a strategic plan. This institutional assessment launched a formal planning process that assembled a broad constituency including hospital/university leaders, faculty, department chairs, residency program directors, program coordinators, residents, nursing and pharmacy leaders, managed care executives and community practitioners. During  a six-month period, the task force succeeded in defining goals, objectives and establishing time lines for managing MUSC’s graduate medical education programs in this new environment. “We wanted to involve people who have a stake in residency education at MUSC,” Medio said. “We felt it was important to get broad participation to create a plan that everyone could support.” While the more immediate purpose was to establish “duty hour” guidelines, the mission of the task force went further and developed a plan to improve the quality of resident education by implementing new competency-based curricula. Resident education revolves around six ACGME-approved competency areas: patient care; medical knowledge; practice-based learning and improvement; interpersonal and written communications skills; professionalism and systems-based practice. In addition, the group also addressed other issues including evaluation and assessment, cost and financial impact, faculty development and the affects of the new regulations on patient care. Of particular importance was the need for each program to design accurate, valid and reliable tools to evaluate the residents. Under the new mandate, resident “duty hours” rely mostly on an honor system in terms of managing and reporting their hours worked. According to George Arana, M.D., associate dean for GME and the program’s Designated Institutional Official (DIO), the system uses a random audit process to assure accountability and accuracy. “In the past, accountability has been our weakness,” Arana said. “We hope to address this with a change in our curriculum program through faculty development. We will focus on the teaching skills of our faculty and their need to more effectively evaluate residents through critical feedback.” Measurable tools, like the E*Value system, play a major part in recording and managing information ranging from “duty hours” to resident performance to clinical and surgical procedures performed. “The E*Value system may be a powerful tool,” according to Arana. “It has been successfully piloted on campus and at other major medical institutions.” MUSC President Ray Greenberg, M.D., Ph.D., has been a strong supporter of residency education. He has praised GME’s efforts emphasizing the critical importance of compliance under these new guidelines and regulations. “It is important that we not jeopardize MUSC’s GME programs,” said Greenberg. “Failure to comply not only affects a program or department, it affects everyone. The new regulations stipulate that the institution is at risk when any program fails to comply.” Not surprisingly, the work of MUSC’s GME Task Force have already gained national attention. This past spring, GME associate deans, Arana and Medio presented the GME Task Force’s work at the Association of American Medical Colleges Group on Resident Affairs Professional Development Meeting in Philadelphia. A month later, they made another presentation to participants at the Association for Hospital Medical Education’s (AHME) national meeting. “We have created a new blueprint for GME at MUSC that has been approved by everyone involved, Medio said. “Although it will take time to achieve the plan’s goals, we feel we are on the right track.” With the local recommendations defined, GME leaders are working to finalize the strategic plan’s objectives and time lines. On Aug. 7, Arana and Medio presented the goals of the strategic plan to MUSC’s Board of Trustees. “These are turbulent times for graduate medical education because of the increased pressures on institutions and residency programs,” Medio said. “The strategic planning process has forced us to look at what we are doing well and address areas where we have fallen short. It will open the door for us to undertake innovative and exciting projects.” Six ACGME-approved competency areas patient care medical knowledge practice-based learning and improvement interpersonal and written communications skills professionalism systems-based practice. Provisions to ACGME Program Requirements Working a maximum of 80 hours per week averaged over four weeks. 10 hours off for rest and personal activities between duty periods and after call. 24-hours maximum continuous on-site duty with up to 6 additional hours permitted for patient transfer and other activities to be defined in RRC requirements. No new patients after 24 hours of continuous duty. Resident time spent in the hospital during at-home call to be counted toward the 80 hours. In-house “moonlighting” may be counted toward the 80 hours. Program directors and faculty to adopt policies to prevent and counteract effects of fatigue. Duty hours to be monitored by the program and sponsor. Residents encourage activism, involvement with changes Pediatric cardiology fellow David Fairbrother and anesthesiology resident Kelby Hutcheson  accept the new July 1 changes imposed towards resident duty hours and residency education. Both believe that resident physicians need more activism in legislation and collaboration regarding current issues that can lead to improvements in the training of new physicians. Both have been continually active early on in medical education and other leadership issues while at MUSC. Today, they remain involved in action and legislation with the American Medical Association (AMA) and locally through the S.C. Medical Association. Their interests and involvement in ACGME’s new policy changes reflect a voice for some of the concerns of MUSC’s 500-member house staff. Recently, stricter guidelines have been placed upon physicians and graduate residency programs at hospitals to improve standards for patient safety and quality for physician training. Hot topics like work fatigue, stress and moonlighting are at the center of new provisions drafted by Association of American Medical Colleges (AAMC). Although many of the residency programs remain unchanged in their training requirements, residents must still complete a number of patient cases within their specialty. This inequality under the new requirements are of concern to many residents.  The new 24/6-hour policy sets limits for physician residents to work after he/she completes a 24-hour shift. The policy restricts physicians from  participating in new patient care or any related medical training six hours prior to completing a work shift. But what defines an impaired physician, asks Hutcheson, who is chair of SCMA's resident and fellow section. “What is required of a physician to be ready to work and practice?,” he asks. One solution is either extend residency training or relax the guidelines, he said. Hutcheson and his colleagues believe this and other ACGME topics require further exploration as it applies to residency education. Hutcheson reminds readers that as of June, there are still legislative bills floating around Washington concerning work residency issues and graduate medical education. “Our hope as residents and members of the AMA is to help raise resident interest within organized medicine to improve working conditions and voice residency concerns through processes like the residency chief’s council and GME’s task force,” Hutcheson said. “This provides us with a voice on local, state and national levels.”         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. 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