Responses have been mixed to a proposal by the Accreditation Council for Graduate Medical Education (ACGME) to increase the number of consecutive hours that first-year medical residents are allowed to work in a day from 16 to 28.
"Study after study shows that sleep-deprived resident physicians are a danger to themselves, their patients and the public," , director of Public Citizen's Health Research Group, said in a statement. "It's disheartening to see the ACGME cave to pressure from organized medicine and let their misguided wishes trump public health."
But the American Academy of Family Physicians (AAFP) had a different take. "The 24 hours [not including 4 hours for transition time] allows greater flexibility, so if the work is completed, one could leave at whatever the appropriate time is, and the resident is not locked into a 16-hour shift," , director of the AAFP's medical education division, said in a phone interview. "I think the ACGME has done its homework -- it has done due diligence around looking at the current literature, and looking at the professional development of learners, and put patient safety right up front."
He added that a survey looking at what happened with the institution of a 16-hour limit in 2011 "found that for first-year residents, quality of life was increased ... but the quality of life went down for everyone else in training" because they had to pick up the slack.
The were issued as part of the council's periodic review and revision of the Common Program Requirements for residency programs. The council formed a task force to examine Section VI of the requirements, which deal with professionalism, personal responsibility, and patient safety; transitions of care; alertness management/fatigue mitigation; supervision of residents; clinical responsibilities; teamwork; and clinical experience and education (formerly known as duty hours).
The Task Force reviewed the published scientific literature on the subject, including on work hours, and also held a hearing in March at which the AAFP and other organizations testified. "After careful consideration of the published literature, the testimony and position of all parties submitting information, and presentations to the Task Force, the Task Force removed the existing requirement limiting PGY-1 residents to 16 hours of consecutive time on-task," , chief executive officer of the ACGME and vice-chair of the task force, wrote in an .
"It is important to note that the absence of a common 16-hour limit does not imply that programs may no longer configure their clinical schedules in 16-hour increments if that is the preferred option for a given setting or clinical context. No action is required by programs that choose to continue this configuration," he added.
The proposal calls for "a limit on consecutive time on-task of 24 hours, plus 4 hours to manage transitions in care," Nasca continued. "Residents, in unusual circumstances and of their own accord, after signing out the care of their patients, may remain to care for a single patient, and the prior onerous documentation burden for this activity was removed. This promotes professionalism, empathy, and commitment."
ACGME also stipulated that specialties including anesthesiology, emergency medicine, and internal medicine that currently set more restrictive shift-length standards could and should continue to do so.
The proposal is consistent with what AAFP and various medical education groups have been recommending Kozakowski said. "The current system of 16 hours for first-year residents creates a couple of dilemmas. One, most importantly, is the increased number of handoffs related to having shorter shifts. As I and others offered in testimony, the challenge is that the increased handoffs creates more opportunities for communication errors among members of healthcare team."
In addition, "the dilemma for individual residents is that they have a conflict between a sense of duty to the patient and the care of the patient, with potentially having to go ahead and hit the clock on time to be out at 16 hours. What we know from stories from residents is that there were times they would leave and [the care for] the patient would be compromised."
As to claims that residents who work 24-hour shifts make more mistakes than those who work shorter hours, "the question is what kind of mistakes," he said. "I don't believe there's been evidence in terms of critical incidents."
The Committee of Interns and Residents (CIR), a 14,000-member labor union for house staff affiliated with the Service Employees International Union, opposes the changes. "Our biggest concern is for the safety and well-being of resident physicians and our patients, and unfortunately these proposed revisions do not improve either of those," , national president of the CIR and a psychiatry resident at Westchester Medical Center, in New York state, said in an email.
"The ACGME says that it is concerned about resident well-being but it puts all the responsibility on residents to stay well under conditions that scientific evidence tells us contribute to stress, burnout, depression and even suicide."
On the other hand, a 2013 survey of surgical residents found that a large majority were chafing under the limits then in place and that some admitted to falsifying reports to conceal the fact that they had worked longer than permitted.
The proposed revisions will be available for 45 days for public comment, after which the task force will review the comments and provide a final set of proposed requirements to the ACGME Board of Directors for consideration and approval. Implementation is targeted for the 2017-2018 academic year, ACGME said.