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Osguthorpe offers update on ACGME changes by Dick Peterson Public Relations A couple years ago weary residents in some specialties, and all program directors, were watching the Accreditation Council on Graduate Medical Education (ACMGE) for expected changes in resident duty hours. If it didn't act, the changes were either going to be made by state legislatures (New York and New Jersey already had enacted duty hour restrictions) or by the federal Occupational Safety and Health Administration. Dr. David Osguthorpe Today, as the ACGME collects data on the effects those sweeping changes have had on residency programs across the nation, MUSC's David Osguthorpe, M.D., is in position to note how well teaching hospitals have complied and to evaluate the effects those changes had. He is the chair of the Resident Review Committee (RRC) Chairs Council and serves on the ACGME's Executive Committee for a term of two years, up a notch from his previous position as chair of the RRC for his specialty, otolaryngology. “The 27 RRCs accredit approximately 8,000 residency programs, specialties and sub-specialties, which have almost 100,000 residents, including all at MUSC,” Osguthorpe said. “If you are not in an ACGME-approved residency, you can't take the certification exams offered by the American Board of Medical Specialties.” Given that level of power over medical education in the U.S., it's not difficult to understand the rapt attention medical schools and their training programs give to the accrediting agency and the committees that hash out the policies the teaching hospitals and residents will ultimately live by. “Last year, the first during which duty hours were in place, only 5 percent of the residency programs were cited for duty hours violations. Most surgical RRCs anticipated that the numbers (of violations) would be high,” Osguthorpe said, “but a preponderance of programs are in compliance.” He said that the area raising the most controversy involves the 10 hours that must occur between duty hour periods. “So if a resident comes in at 6 a.m. for rounds, they would have had to have been gone home by 8 p.m. the night before. The wording on that is 'should,' not 'must,' a nuance the RRC chairs favored, so there is some latitude.” He said that another issue involves the allowable in-house interval after 24 hours on call in house, of which there are many at MUSC. A resident can spend only six more hours in the hospital before being required to go home. “This has not affected specialties like anesthesia or emergency medicine, where if a person is on a 24-hour shift, they have always gone home.” The impact, Osguthorpe said, hits mostly the small specialties and sub-specialties. Citing his own specialty, otolaryngology, as an example, Osguthorpe said that when a person has a tracheostomy, that patient is observed overnight in an intensive care unit. “The patient had substantial breathing problems to begin with, so if the tube comes out, it can become an immediate respiratory issue, in a field with a fresh wound. If that happens, it would be optimal if an otolaryngology resident who took part in the surgical management were immediately available rather than taking call at home. However, for smaller residencies, say those with fewer than 10 to 12 residents, it is usually not feasible to have in-house call. Fortunately, university teaching hospitals such as ours have both anesthesia and surgical trauma teams in house, a resource not available in most private hospitals.” Concurrent with the duty hours, resident training was defined in terms of the acquisition of six basic competencies, a new system being phased in over a seven-year period. Two of them, interpersonal communication skills and professionalism, Osguthorpe said, are actively taught at MUSC by Franklin Medio, Ph.D., of the Medical School's Graduate Medical Education group. Medio is going from department to department presenting lectures to the residents and faculty. “MUSC is ahead of the national curve on this issue, and is to be congratulated in my opinion.” As for what's going on at the ACGME right now, Osguthorpe reported that the RRC Chair's Council recently endorsed a proposal to mandate institutional financial support for program directors, with the level of support dependent on specialty and number of residents supervised. “Every residency at MUSC has a program director,” he said. “They are the ones who are supposed to follow residents' progress, meet periodically with them, develop their educational programs and any needed remedial measures, make sure the rotations are rewarding and so forth. “In all too many programs, the program director is doing it on their own dime and time.” As a result, the national turnover rate for program directors is 15 percent per year (much higher in some specialties), Osguthorpe said. “Way too high. The job is frequently put off on junior faculty or those with competing time commitments and as a result many clinical departments are not retaining their best and brightest.” Although RRC to a program director “is a truncated version of a four-letter word, RRCs want the program directors to have protected time and direct institutional support without having to generate the funds to cover such themselves,” Osguthorpe said.  The reason for the occasional animosity between program directors and their specialty's RRC is obvious; their task is difficult to begin with, and to have an RRC come along and point out all the program director is doing wrong, frequently due to institutional issues outside their control, adds to the difficulty. To mandate protected time and modest income for the program directors could help to ease their frustration and ensure the quality of the residency program. Osguthorpe said that also under way is an attempt to improve consistency among RRCs. “There are 27 of them and there are distinct differences in how they function and how strict they are.” He explained that one residency program could be found to have 10 deficiencies and still receive a five-year review cycle, while another program may be deficient in only two areas, yet be given a three-year review cycle.   Considered will be a stratification of citations based on severity. “Right now all citations are equal, but they are not really equal. Having all your residents flunk the board exam is a major issue, but having all your paperwork not quite together at the time of a site visit is a lesser issue. Right now they are both citations. We need to define what serious is.” And they are in a tree-sparing mode, he said. “Otolaryngology, for instance, took what is called a program information form (PIF) and reduced it by 40 percent. Every program director hates this form. It's huge. They have to fill it out when their site visit comes up, and much of the information required is not germane.” He said that all the RRCs are following the lead and by next year the basic PIF form will be online. “You could log on one day, fill out 20 things, save it and come back the next month and fill in some more. It's going to be good news to everybody.” Osguthorpe said, “The final thing that's driving everybody nuts is procedural competency.” He said that one resident might be quite competent at a basic procedure after doing it two or three times, while another resident may take a dozen times to achieve competency. The ABMS boards only examine with written, and in some cases verbal, tests, but until computer simulations become sufficiently sophisticated to assess procedural skills, these program directors and RRCs are stuck with figuring out what constitutes basic competency in procedural tasks. He said he was not just talking about surgeons, but also about cardiologists, gastroenterologists, interventional radiologists, pulmonologists, procedural dermatologists and the like.  “There needs to be something at the training level that certifies that a resident can do such and such as they move through their residency. The Canadians have a very good system for this and the gastroenterologists have a schema that seems fairly comprehensive.” He said the RRC chairs will be meeting with representatives of the ABMS and the American College of Surgeons within the next few months, and then have a retreat this September to decide which basic system to adopt.      Friday, April 1, 2005 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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