Duty-hour Requirements Research Articles

Perceptions of the 2011 ACGME duty hour requirements among residents in all core programs at a large academic medical center

BackgroundThe Accreditation Council for Graduate Medical Education (ACGME) implemented revisions to resident duty hour requirements (DHRs) in 2011 to improve patient safety and resident well-being. Perceptions of DHRs have been reported to vary by training stage and specialty among internal medicine and general surgery residents. The authors explored perceptions of DHRs among all residents at a large academic medical center.MethodsThe authors administered an anonymous cross-sectional survey about DHRs to residents enrolled in all ACGME-accredited core residency programs at their institution. Residents were categorized as medical and pediatric, surgery, or other.ResultsIn total, 736 residents representing 24 core specialty residency programs were surveyed. The authors received responses from 495 residents (67%). A majority reported satisfaction (78%) with DHRs and believed DHRs positively affect their training (73%). Residents in surgical specialties and in advanced stages of training were significantly less likely to view DHRs favorably. Most respondents believed fatigue contributes to errors (89%) and DHRs reduce both fatigue (80%) and performance of clinical duties while fatigued (74%). A minority of respondents (37%) believed that DHRs decrease medical errors. This finding may reflect beliefs that handovers contribute more to errors than fatigue (41%). Negative perceived effects included diminished patient familiarity and continuity of care (62%) and diminished clinical educational experiences for residents (41%).ConclusionsA majority of residents reported satisfaction with the 2011 DHRs, although satisfaction was significantly less among residents in surgical specialties and those in advanced stages of training.

Resident Physician Duty-hour Requirements: What Does the Public Think?

To date, no study has reported on the public's opinion of orthopaedic resident duty-hour requirements (DHR). A survey was administered to people in orthopaedic waiting rooms and at three senior centers. Responses were analyzed to evaluate seven domains: knowledge of duty hours; opinions about duty hours; attitudes regarding shift work; patient safety concerns; and the effects of DHRs on continuity of care, on resident training, and on resident professionalism. Respondents felt that fatigue was unsafe and duty hours were beneficial in preventing resident physician fatigue. They supported the idea of residents working in shifts but did not support shifts for attending physicians. However, respondents wanted the same resident to provide continuity of care, even if that violated DHRs. They were supportive of increasing the length of residency to complete training. DHRs were not believed to affect professionalism. Half of the respondents believed that patient opinion should influence policy on this topic. Orthopaedic patients and those likely to require orthopaedic care have inconsistent opinions regarding DHRs, making it potentially difficult to incorporate their preferences into policy.

Are Duty-Hour Changes Having Desired Effect?

Back to table of contents Previous article Next article Professional NewsFull AccessAre Duty-Hour Changes Having Desired Effect?Aaron LevinAaron LevinSearch for more papers by this authorPublished Online:17 May 2013https://doi.org/10.1176/appi.pn.2013.5b16AbstractDid a change in shift length for medical interns give them more time to sleep and result in fewer medical errors?Give first-year medical residents a few extra hours off work and what do you get? Not much, aside from a bit more anxiety, according to Srijan Sen, M.D., an assistant professor of psychiatry at the University of Michigan.Srijan Sen, M.D., Ph.D., looks at the intersection of genetics, stress, and depression—a place where he finds lots of first-year medical residents.Aaron LevinSen studies the interaction of genes, stress, and depression, so PGY-1s make attractive research targets.“We’ve been studying interns as a model of stress,” said Sen in an interview with Psychiatric News. “It’s one of those rare situations where relatively happy people are going to be stressed out, and a high percentage will be depressed in a few months.”With several colleagues, he began tracking interns in 2006 when he was a resident at Yale. His current clinical work includes seeing physicians in training who are struggling with depression.The researchers so far have recruited more than 4,500 interns and add 800 to 1,000 more each year, collecting DNA in the spring before their internships start. Sen hopes to continue the study for another four or five years to gather sufficient numbers to power observations of what are likely to be small genetic effects.The current cohort—the seventh so far—served to highlight changes in duty-hour requirements starting in July 2011, as recommended by the Accreditation Council for Graduate Medical Education (ACGME).About 58 percent of invited medical interns from 22 U.S. institutions agreed to participate in the study. Half were heading into internal medicine, about 10 percent to 15 percent were planning to become psychiatrists, and the rest were from other specialties.“Reported duty hours decreased from an average of 67.0 hours per week before the new rules to 64.3 hours per week after the new rules were instituted,” the researchers said online March 25 in JAMA Internal Medicine. The reduced duty hours added an insignificant 12 minutes of extra sleep per day and didn’t alter rates of depressive symptoms or measures of well-being for the interns.“Different strategies for improving resident education and patient care may be necessary to achieve the desired impact of ACGME reforms,” they concluded.“It’s not clear what those interns were doing with those extra three hours,” Sen told Psychiatric News. “The three-hour drop per week in work hours might not be as much as was hoped for or expected by ACGME.”However, interns did report a significant increase (from 19.9 percent to 23.3 percent) in concern about making medical errors. “I think this relates to communication problems at handoffs,” said Sen. “With a decrease in shift lengths, interns get more times [at which they] pass off care to the next shift. Now, patients may see two or three interns in their first day in the hospital instead of just one.”The study recorded the interns’ “concern” about possible errors, not actual charted mistakes. Sen would like to cross-check the two factors in a subsample of a future cohort.Also, the new ACGME rules cut the maximum shift length but did not restrict the actual work interns need to perform, suggested Sen. “They were expected to do the same work in less time,” he said. “Not only didn’t that reduce stress, it may have increased it.”However, 2011 was the first year for the new rules, and hospitals may not have fully adjusted work schedules, he said. Outcomes might change as hospitals and senior physicians become accustomed to the new rules.Aside from that, Sen offers another hypothesis about interns’ response to the new hours. Back in the “bad old days,” interns getting off a 24-hour shift had enough free time to run errands and catch up on sleep before they reported back for duty. “Now work is more intense, and there’s no stress-relieving time,” he suggested. ■An abstract of “Effects of the 2011 Duty-Hour Reforms on Interns and Their Patients” is posted at http://archinte.jamanetwork.com/article.aspx?articleid=1672284. ISSUES NewArchived

Duty-Hour Requirements Put Residents in Ethical Quandary

Duty-Hour Requirements Put Residents in Ethical Quandary

Use of text messaging (TM) to enhance compliance with the Accreditation Council for Graduate Medical Education (ACGME) resident duty-hour (RDH) requirements: a pilot study

Use of text messaging (TM) to enhance compliance with the Accreditation Council for Graduate Medical Education (ACGME) resident duty-hour (RDH) requirements: a pilot study

Effect of Residency Duty-Hour Limits

To determine the effect of duty-hour limitations, it is important to consider the views of faculty who have the most contact with residents. We conducted a national survey of key clinical faculty (KCF) at 39 internal medicine residency programs affiliated with US medical schools selected by random sample stratified by federal research funding and program size to elicit their views on the effect of duty-hour limitations on residents' patient care, education, professionalism, and well-being and on faculty workload and satisfaction. Of 154 KCF surveyed, 111 (72%) responded. The KCF reported worsening in residents' continuity of care (87%) and the physician-patient relationship (75%). Faculty believed that residents' education (66%) and professionalism, including accountability to patients (73%) and ability to place patient needs above self-interests (57%), worsened, yet 50% thought residents' well-being improved. The KCF reported spending more time providing inpatient services (47%). Faculty noted decreased satisfaction with teaching (56%), ability to develop relationships with residents (40%), and overall career satisfaction (31%). In multivariate analysis, KCF with 5 years of teaching experience or more were more likely to perceive a negative effect of duty hours on residents' education (odds ratio, 2.84; 95% confidence interval, 1.15-7.00). Key clinical faculty believe that duty-hour limitations have adversely affected important aspects of residents' patient care, education, and professionalism, as well as faculty workload and satisfaction. Residency programs should continue to look for ways to optimize experiences for residents and faculty within the confines of the duty-hour requirements.

Implementation and Evaluation of a New Surgical Residency Model

The Accreditation Council for Graduate Medical Education (ACGME) duty-hour requirements prompted program directors to rethink the organizational structure of their residency programs. Many surgical educators have expressed concerns that duty-hour restrictions would negatively affect quality of resident education. This article summarizes evaluation research results collected to study the impact of our reengineered residency program designed to preserve important educational activities while meeting duty-hour accreditation requirements. The traditional residency structure was redesigned to include a mixture of apprenticeship, small team, and night-float models. Impact evaluation data were collected using operative case logs, standardized test scores, quality assurance data, resident perception surveys, a faculty survey, and process evaluation measures. PGY1s and PGY2s enjoyed a substantial increase in operative cases. Operative cases increased overall and no resident has failed to meet ACGME volume or distribution requirements. American Board of Surgery In-Training Examination performance improved for PGY1s and PGY2s. Patient outcomes measures, including monthly mortality and number of and charges for admissions, showed no changes. Anonymously completed rotation evaluation forms showed stable or improved resident perceptions of case load, continuity, operating room teaching, appropriate level of faculty involvement and supervision, encouragement to attend conferences, and general assessment of the learning environment. A quality-of-life survey completed by residents before and after implementation of the new program structure showed substantial improvements. Faculty surveys showed perceived increases in work hours and job dissatisfaction. New physician assistant and nurse positions directly attributed to duty-hour restrictions amounted to about 0.2 full-time equivalent per resident. Duty-hour restrictions produce new challenges and might require additional resources but need not cause a deterioration of surgical residents' educational experience.

Work Hours Restrictions as an Ethical Dilemma for Residents: A Descriptive Survey of Violation Types and Frequency

The Accreditation Council for Graduate Medical Education (ACGME) implemented requirements regarding allowable duty hours for resident training in the United States in July 2003. In a previous pilot study at Vanderbilt University Medical Center, a significant number of residents reported violation of requirements. In addition, almost half of those individuals admitted under-reporting their hours worked. The authors' goal was to further delineate the type and frequency of violations and under-reporting. A survey tool was designed to assess specific types of violations as well as factors that influence the number of hours residents worked and reported. Approval was obtained from the Vanderbilt Institutional Review Board and Office of Graduate Medical Education before enrollment of subjects. The program directors of Pediatrics, Internal Medicine, Medicine-Pediatrics, and General Surgery supported the participation of their residents. A voluntary anonymous survey of these residents was conducted 1 year after the pilot study. Of 263 eligible residents, 175 were surveyed. Of 175 residents, 125 (71%) residents responded. Eighty-five percent of residents reported violation of duty-hour requirements within the preceding 3 months. Residents reported violation of specific requirements as follows: 1 day off in 7, 28%; 80-hour weekly average, 65%; and "24+6" consecutive hours, 85%. Residents were asked to estimate the number of hours by which they exceeded requirements. Hours over the 80-hour weekly requirement were reported as follows: 1 hour, 12%; 2 hours, 15%; 3 hours, 21%; 4 hours, 5%; 5 hours, 14%; and 6 or more hours, 33%. Hours over the "24+6" requirement were reported as follows: 1 hour, 30%; 2 hours, 42%; 3 hours, 18%; 4 hours, 7%; 5 hours, 1%; and 6 or more hours, 2%. Forty-eight percent of respondents admitted under-reporting violations to their program director. Eighty-five percent of residents reported at least 1 violation, and 48% admitted under-reporting violations. These results support the previous findings of 80% and 49%, respectively. Of the various requirements, the "24+6" rule was most frequently violated. Of those in violation of the "24+6" requirement, the majority (90%) exceeded limits by no more than 3 hours. Of those in violation of the 80-hour weekly average requirement, the majority (57%) exceeded limits by no more than 5 hours. Per the ACGME website, "an RRC may grant exceptions for up to 10% of the 80-hour limit, to individual programs based on a sound educational rationale." Although the overall percent of residents reporting violation remains high, the number of excess hours worked is small relative to established standards (within 10%). The authors propose that systems adaptations could be developed to improve compliance. Special attention is warranted to investigate the activities of residents in the post-call period.

Implementing Duty-Hour Restrictions Without Diminishing Patient Care or Education: Can It Be Done?

To implement and evaluate a new ward team call system that would meet the Accreditation Council on Graduate Medical Education's (ACGME) duty-hour requirements without compromising patient care or detracting from resident education. The new system was implemented in the internal medicine residency program at the University Hospital at the University of Cincinnati Medical Center. In 2003-04, residents and faculty were surveyed about their experiences with the new and old ward systems relative to duty-hour requirements, patient care, and resident education. Responses were given on a five-point scale (5 = strongly agree, 1 = strongly disagree). Data were compiled and compared using a two-sample t-test. Faculty believed the new system improved compliance with the duty-hour requirements (mean = 4.3, 95% confidence interval [CI]: 4.1-4.6), although were neutral regarding patient care (mean = 3.5, 95% CI: 3.2-3.8) and education (mean = 3.3, 95% CI: 2.9-3.6). Residents were more neutral regarding ACGME requirements (mean = 3.5, 95% CI: 3.3-3.7) and patient care (mean = 3.2, 95% CI 3.0-3.3). Residents reported a slightly negative impact on education (mean = 2.8, 95% CI: 2.5-3.0). In response to an exclusive question, residents reported that the new system did not reduce fatigue (mean = 2.7, 95% CI: 2.6-3.0). Respondents perceived that this ward call system met ACGME requirements and maintained quality patient care but may have sacrificed some traditional resident education tenets.

Resident job satisfaction: One year of duty hours

This study was undertaken to assess job satisfaction and quality of life aspects among residents in obstetrics/gynecology before and after the implementation of duty-hour requirements. We administered a survey to residents before and after duty-hour restrictions, addressing satisfaction with residency training, quality of life, and predictions/impressions of the effect of reduced work hours. Satisfaction with overall residency training as a discrete survey item did not change; however, the composite score from all responses to specific items increased. Several specific clinical and academic items garnered higher satisfaction scores in 2004. Residents reported less-than-anticipated increases in healthiness of their lifestyle and a decrease in interest in teaching. This is a prospective assessment of the effect of duty-hour requirements, improvements in residents' perception of their time and ability to study and pursue research and in clinical areas are encouraging. The perception that there is less interest in teaching is of concern.

Brief communication of the Residency Review Committee-Surgery (RRC-S) on residents’ surgical volume in general surgery

Background The Residency Review Committee-Surgery (RRC-S), 1 of 10 surgical specialties of the Accreditation Council for Graduate Medical Education (ACGME) has monitored the surgical volume of all general surgical residents closely. As a consequence of the reduction of duty hours with the limitation of an 80-hour work-week (averaged over 4 weeks), we were interested in the impact of these restrictions on surgical (volume) experience since its first year of implementation (2003–2004). Therefore, we evaluated the surgical volume of general surgical services since the implementation of the ACGME duty-hour restrictions and compared this volume with that of previous years without these duty limits. Methods The Biostatistical Management Section of the ACGME implemented prospective analysis of categorized data for total surgical procedures and Chief Resident cases. The study interval included all resident surgical procedures completed from 1997 to 2004. We were interested particularly in evaluating trends and outcomes after the first year of successful full compliance of the 80-hour work week. Specific evaluations included the impact on surgical programs for total major procedures and Chief Resident cases requisite for application to the American Board of Surgery. Results The average number of total major procedures for both resident and program averages were noted to increase steadily through the academic years of evaluation (1997–2001). A sharp decrease was evident in the total major procedures for the academic year 2001–2002 that relates to a correction of the biostatistical database implemented by the ACGME to correct a system conversion that began in the academic year 2001–2002. Despite significant changes to the system data mappings, beginning in the academic year 2001, this reduction is explained by the total counted surgeries as major that were eliminated in a revised counting methodology. It was evident on evaluation of the average (of averages) for major surgical procedures per resident (per program) in academic years 1997 to 2004 that the number of procedures was not statistically different in the academic years evaluated when compared with the year for implementation of duty-hour standards (2003–2004). Data analysis further indicates that the average procedures (per resident) performed as Chief Resident in general surgery remained stable from 1997 to 2004; the use of tiered t tests comparing Chief Resident averages (per program) for the academic years 2002–2003 versus 2003–2004 indicated that data remained consistent and confirmed no statistical variance in volumes during this interval ( P = 0.43). Because some general surgery programs have exceptions for duty-hour requirements (n = 15) to allow an 88-hour week averaged over 4 weeks, these differences were of interest to evaluate programs with and without these duty-hour exceptions. Preliminary data with these limited parameters of evaluation suggest no detrimental outcomes related to the duty-hour restrictions for total major procedures per resident or for surgical procedures as Chief Residents for programs with and without these approved exceptions. Conclusions RRCs that evaluate general surgery and surgical specialties have responded aggressively and professionally to implement the duty-hour standards per the ACGME. This brief report should be considered an interim communication to evaluate the surgical experience impact for programs currently under the restriction of duty-hour limits. The data provided in the first year of evaluation since the implementation of the 80-hour work-week restriction policy suggest that there has been no significant change in the overall surgical experience for major procedures (per resident), nor has there been a negative impact on Chief Resident surgical experience. A continuum of the prospective evaluation process is required by the RRC-S and other surgical specialties to ensure that requisite surgical volume is maintained throughout the entire 5 years of clinical surgery.

Special features topic: the effects of limited work hours on surgical training in otolaryngology-head and neck surgery.

This paper reviews the historic events that culminated in the development of duty hour regulations, and then discusses many of the problems being encountered as the regulations are implemented. On July 3, 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted duty hour requirements for residency training programs in the United States. Although these regulations should have come as no surprise to graduate medical education programs, many were nevertheless unprepared for their implementation. In comparison to duty hour restrictions currently in place in European countries, those being implemented in this country are much more lenient. Both the fiscal and the educational impact of these requirements on graduate medical education are substantial. Recent accreditation actions taken against a training program at Johns Hopkins University clearly demonstrates that the ACGME is prepared to strictly enforce these standards. The impact of the new duty-hour requirements on residency training and education will be a matter of great interest as they are implemented throughout the graduate education system in the United States.