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SAN FRANCISCO -- The American College of Surgeons could consider taking over resident training from the Accreditation Council of Graduate Medical Education to avoid the council's latest duty-hour restrictions, which went into effect in July.
In considering strategies to address the unwelcome restrictions, "we haven't taken anything off the table," said Dr. L.D. Britt, immediate past president of the American College of Surgeons (ACS) and chair of the ACS Task Force on Resident Duty Hours. "We shouldn't allow any entity to destroy our training programs."
At least one College official later said the College has no plans to take over accreditation of residency programs, but the mere mention of this possibility as an option drew cheers at an emotional, standing-room-only session on resident duty hours during the annual Clinical Congress of the American College of Surgeons.
Dr. Britt and a panel of ACS leaders described their efforts thus far to modify the new duty-hour requirements before and after they went into effect. The session was the first time surgeons had gathered in large numbers since the new rules went into effect, and many of them vented their frustrations.
They objected most to the 16-hours/day limit on first-year residents. "The 16-hour day is an enemy to education," said Dr. Britt, an ACS Fellow and Brickhouse Professor of Surgery and Chairman at Eastern Virginia Medical School, Norfolk.
Limitations on the work hours of surgical trainees in England, Switzerland, and other European countries have been "devastating" to the quality of education there, he said. "Why aren't they looking at the international experience?" Dr. Britt asked in a lengthy discussion session after the formal presentations.
He and others emphasized that there are no data showing that reduced hours lead to better patient outcomes. On the contrary, the limits could hurt patients by increasing the risk for errors because the new schedule leads to an increased number of patient hand-offs and gives residents less experience, they suggested.
Dr. Ajit K. Sachdeva, an ACS Fellow, director of the ACS Division of Education, and moderator of the session, said in a phone interview afterward that there has been "a lot of chatter" on ACS listservs about the duty-hour restrictions, but the ACS "has no plans" to take over residency program accreditations.
"There's a prevailing sense in the surgical community that the 16 hours a day is not going to be good for surgical training and actually will do harm, because you will have less well-trained people in the future," said Dr. Sachdeva, adjunct professor of surgery at Northwestern University, Chicago. The ACS will continue to try to get the Accreditation Council of Graduate Medical Education (ACGME) to expand the daily 16-hour limit for first-year residents and to keep the 80-hour weekly limit from shrinking.
Under the 2011 regulations, residents must break the rules to get needed experience in continuity of care, said Dr. Thomas V. Whalen, an ACS Fellow and chief medical officer, department of surgery, Lehigh Valley Health Network, Allentown, Pa.
Dr. Whalen, who served on the ACGME task force that reviewed and revised the 2003 regulations, said that pressure for tighter limits on resident duty hours came largely from sleep scientists such as Dr. Charles A. Czeisler, professor and director of the division of sleep medicine, Harvard University, and chief of the division of sleep medicine at Brigham and Women's Hospital, Boston.
Dr. Czeisler said in an interview that he is an advocate of patient safety and evidence-based medicine. "In fact, this year is the 40th anniversary of the first study demonstrating that extended-duration shifts double the rate of errors that interns make when detecting cardiac arrhythmias," he said. Since then, his research has shown that work shifts longer than 24 hours lead to a 460% increase in serious diagnostic mistakes made by resident physicians caring for critically ill patients in the ICU, a 73% increase in the risk of percutaneous injuries, and a 168% increase in the odds of a resident being in a motor vehicle crash while driving home, among other adverse consequences.
An Institute of Medicine (IOM) consensus statement in December 2008 recommended, among other things, that 5 hours of sleep be allowed after any shift longer than 16 hours, and that this sleep time be counted toward the 80-hour/week limit, averaged over 4 weeks.
The ACS published a detailed response to the IOM report, arguing that the 16 hours/day limit "is entirely unworkable in the surgical environment" (Surgery 2009;146:398-409).
The ACGME rules don't go as far as the IOM recommendations because the ACGME applied the 16 hours/day limit only to interns and not to other residents, Dr. Czeisler has noted in previously published statements.
Limiting duty shifts for surgical residents will not necessarily hurt the quality of education or increase the number of years of training needed, according to Dr. Czeisler. He pointed out that "surgeons in New Zealand have been training with a 16-hour shift limit since 1985, without needing a longer training program."
Dr. Mark L. Friedell, an ACS Fellow and president of the Association of Program Directors in Surgery, suggested that the fourth year of medical school could be used to prepare students for surgical residency. Dr. Sachdeva said that the ACS is working with other organizations to develop a surgery "boot camp" for fourth-year medical students.
Another helpful alternative would be to develop a "milestone" for first-year residents that might make the ACGME feel comfortable in letting them work 24 consecutive hours, like other residents, said Dr. Friedell, who directs the residency program in general surgery at Orlando Health, a network of hospitals.
Reports from five residency programs on their experience thus far with duty-hour restrictions suggest that surgery interns now are working 6 days/week, and "golden weekends" have disappeared. Patient hand-offs have increased in many programs. Faculty and senior residents are under more stress as more of the workload shifts to them. Many programs have hired additional nurse practitioners and physician assistants to help handle the work residents no longer do.
First-year residents report that they do not feel blamed for the restrictions, but many feel they are being shortchanged by not having the same duty hours as other residents, Dr. Friedell said.
"Part of the reason we're in the mess we're in is because we didn't pay enough attention to what residents did in the pre-80-hour era," said Dr. Joshua M.V. Mammen, assistant professor at the University of Kansas, Kansas City, and past chair of the ACS Resident and Associate Society (RAS). He echoed a theme suggesting that enhanced supervision of residents -- rather than limiting duty hours -- is the key to safe practice.
In a 2006 Internet-based survey of RAS members, approximately 60% said that, ideally, residents should work less than 80 hours/week, and 40% favored more than 80 hours/week, said Dr. Mammen. In an ongoing survey of current RAS members with 841 respondents so far, it's more of a 50-50 split, he said. In all, 48% said that residents should work 60-80 hours/week, 47% believed 61-100 hours/week would be ideal, 2% favored fewer than 60 hours/week, and 3% wanted residents working more than 100 hours/week.
The speakers had no conflicts.
This newest version of ACGME work hour regulation has created significant challenges for program directors, faculty and residents alike, unfortunately without any evidence that it will be of benefit to trainees, patients, or the educational process. While the overall number of hours per week is unchanged at 80, there are numerous new restrictions which create logistical difficulties for both programmatic management and patent care.
These center around the length of time that residents can work consecutively, as well as the number of hours required to be off duty between duty periods. Specifically, first year residents may not spend more than 16 hours on duty at a time (compared to 24 hours previously and for more senior trainees); in addition, eight hours between duty periods is now mandatory, compared to the "suggested" ten hours previously indicated, and lastly there is added regulation around time off following a 24-hour shift and night float.
| Dr. Shortell |
Such restrictions, which at first glance may seem fairly minor, create additional difficulties in scheduling, but perhaps more importantly, have the potential to impact continuity of care for patients in significant ways. Consider that with every new restriction on duty hours, more hand-offs are required, with each hand-off having the potential to affect continuity of care. In addition, each hand-off takes time - time which could be otherwise devoted to educational experiences and care of patients. Astonishingly, despite placing all these additional restrictions around resident work hours, moonlighting, an activity which provides no educational opportunities, remains an acceptable activity for trainees.
Ultimately, we must ask whether the potential (but unproven) benefits noted above gleaned from duty hour restrictions are worth the loss of opportunity to patients and residents that is afforded by continuous care by an individual physician.
It is important to note that the addition of physician extenders, which has been a strategy utilized to reduce service requirements in the past, would not address the above concerns, as hand-offs would still be required. Regardless of the validity of these changes, they are here to stay for the foreseeable future, and it will be our responsibility as surgeons and educators to develop ways to maximize patient care and resident education in the face of these new regulations.
Cynthia K. Shortell, MD, is a professor of surgery and chief of vascular surgery and program director, vascular residency at Duke University Medical Center, Durham, N.C.
This newest version of ACGME work hour regulation has created significant challenges for program directors, faculty and residents alike, unfortunately without any evidence that it will be of benefit to trainees, patients, or the educational process. While the overall number of hours per week is unchanged at 80, there are numerous new restrictions which create logistical difficulties for both programmatic management and patent care.
These center around the length of time that residents can work consecutively, as well as the number of hours required to be off duty between duty periods. Specifically, first year residents may not spend more than 16 hours on duty at a time (compared to 24 hours previously and for more senior trainees); in addition, eight hours between duty periods is now mandatory, compared to the "suggested" ten hours previously indicated, and lastly there is added regulation around time off following a 24-hour shift and night float.
| Dr. Shortell |
Such restrictions, which at first glance may seem fairly minor, create additional difficulties in scheduling, but perhaps more importantly, have the potential to impact continuity of care for patients in significant ways. Consider that with every new restriction on duty hours, more hand-offs are required, with each hand-off having the potential to affect continuity of care. In addition, each hand-off takes time - time which could be otherwise devoted to educational experiences and care of patients. Astonishingly, despite placing all these additional restrictions around resident work hours, moonlighting, an activity which provides no educational opportunities, remains an acceptable activity for trainees.
Ultimately, we must ask whether the potential (but unproven) benefits noted above gleaned from duty hour restrictions are worth the loss of opportunity to patients and residents that is afforded by continuous care by an individual physician.
It is important to note that the addition of physician extenders, which has been a strategy utilized to reduce service requirements in the past, would not address the above concerns, as hand-offs would still be required. Regardless of the validity of these changes, they are here to stay for the foreseeable future, and it will be our responsibility as surgeons and educators to develop ways to maximize patient care and resident education in the face of these new regulations.
Cynthia K. Shortell, MD, is a professor of surgery and chief of vascular surgery and program director, vascular residency at Duke University Medical Center, Durham, N.C.
This newest version of ACGME work hour regulation has created significant challenges for program directors, faculty and residents alike, unfortunately without any evidence that it will be of benefit to trainees, patients, or the educational process. While the overall number of hours per week is unchanged at 80, there are numerous new restrictions which create logistical difficulties for both programmatic management and patent care.
These center around the length of time that residents can work consecutively, as well as the number of hours required to be off duty between duty periods. Specifically, first year residents may not spend more than 16 hours on duty at a time (compared to 24 hours previously and for more senior trainees); in addition, eight hours between duty periods is now mandatory, compared to the "suggested" ten hours previously indicated, and lastly there is added regulation around time off following a 24-hour shift and night float.
| Dr. Shortell |
Such restrictions, which at first glance may seem fairly minor, create additional difficulties in scheduling, but perhaps more importantly, have the potential to impact continuity of care for patients in significant ways. Consider that with every new restriction on duty hours, more hand-offs are required, with each hand-off having the potential to affect continuity of care. In addition, each hand-off takes time - time which could be otherwise devoted to educational experiences and care of patients. Astonishingly, despite placing all these additional restrictions around resident work hours, moonlighting, an activity which provides no educational opportunities, remains an acceptable activity for trainees.
Ultimately, we must ask whether the potential (but unproven) benefits noted above gleaned from duty hour restrictions are worth the loss of opportunity to patients and residents that is afforded by continuous care by an individual physician.
It is important to note that the addition of physician extenders, which has been a strategy utilized to reduce service requirements in the past, would not address the above concerns, as hand-offs would still be required. Regardless of the validity of these changes, they are here to stay for the foreseeable future, and it will be our responsibility as surgeons and educators to develop ways to maximize patient care and resident education in the face of these new regulations.
Cynthia K. Shortell, MD, is a professor of surgery and chief of vascular surgery and program director, vascular residency at Duke University Medical Center, Durham, N.C.
SAN FRANCISCO -- The American College of Surgeons could consider taking over resident training from the Accreditation Council of Graduate Medical Education to avoid the council's latest duty-hour restrictions, which went into effect in July.
In considering strategies to address the unwelcome restrictions, "we haven't taken anything off the table," said Dr. L.D. Britt, immediate past president of the American College of Surgeons (ACS) and chair of the ACS Task Force on Resident Duty Hours. "We shouldn't allow any entity to destroy our training programs."
At least one College official later said the College has no plans to take over accreditation of residency programs, but the mere mention of this possibility as an option drew cheers at an emotional, standing-room-only session on resident duty hours during the annual Clinical Congress of the American College of Surgeons.
Dr. Britt and a panel of ACS leaders described their efforts thus far to modify the new duty-hour requirements before and after they went into effect. The session was the first time surgeons had gathered in large numbers since the new rules went into effect, and many of them vented their frustrations.
They objected most to the 16-hours/day limit on first-year residents. "The 16-hour day is an enemy to education," said Dr. Britt, an ACS Fellow and Brickhouse Professor of Surgery and Chairman at Eastern Virginia Medical School, Norfolk.
Limitations on the work hours of surgical trainees in England, Switzerland, and other European countries have been "devastating" to the quality of education there, he said. "Why aren't they looking at the international experience?" Dr. Britt asked in a lengthy discussion session after the formal presentations.
He and others emphasized that there are no data showing that reduced hours lead to better patient outcomes. On the contrary, the limits could hurt patients by increasing the risk for errors because the new schedule leads to an increased number of patient hand-offs and gives residents less experience, they suggested.
Dr. Ajit K. Sachdeva, an ACS Fellow, director of the ACS Division of Education, and moderator of the session, said in a phone interview afterward that there has been "a lot of chatter" on ACS listservs about the duty-hour restrictions, but the ACS "has no plans" to take over residency program accreditations.
"There's a prevailing sense in the surgical community that the 16 hours a day is not going to be good for surgical training and actually will do harm, because you will have less well-trained people in the future," said Dr. Sachdeva, adjunct professor of surgery at Northwestern University, Chicago. The ACS will continue to try to get the Accreditation Council of Graduate Medical Education (ACGME) to expand the daily 16-hour limit for first-year residents and to keep the 80-hour weekly limit from shrinking.
Under the 2011 regulations, residents must break the rules to get needed experience in continuity of care, said Dr. Thomas V. Whalen, an ACS Fellow and chief medical officer, department of surgery, Lehigh Valley Health Network, Allentown, Pa.
Dr. Whalen, who served on the ACGME task force that reviewed and revised the 2003 regulations, said that pressure for tighter limits on resident duty hours came largely from sleep scientists such as Dr. Charles A. Czeisler, professor and director of the division of sleep medicine, Harvard University, and chief of the division of sleep medicine at Brigham and Women's Hospital, Boston.
Dr. Czeisler said in an interview that he is an advocate of patient safety and evidence-based medicine. "In fact, this year is the 40th anniversary of the first study demonstrating that extended-duration shifts double the rate of errors that interns make when detecting cardiac arrhythmias," he said. Since then, his research has shown that work shifts longer than 24 hours lead to a 460% increase in serious diagnostic mistakes made by resident physicians caring for critically ill patients in the ICU, a 73% increase in the risk of percutaneous injuries, and a 168% increase in the odds of a resident being in a motor vehicle crash while driving home, among other adverse consequences.
An Institute of Medicine (IOM) consensus statement in December 2008 recommended, among other things, that 5 hours of sleep be allowed after any shift longer than 16 hours, and that this sleep time be counted toward the 80-hour/week limit, averaged over 4 weeks.
The ACS published a detailed response to the IOM report, arguing that the 16 hours/day limit "is entirely unworkable in the surgical environment" (Surgery 2009;146:398-409).
The ACGME rules don't go as far as the IOM recommendations because the ACGME applied the 16 hours/day limit only to interns and not to other residents, Dr. Czeisler has noted in previously published statements.
Limiting duty shifts for surgical residents will not necessarily hurt the quality of education or increase the number of years of training needed, according to Dr. Czeisler. He pointed out that "surgeons in New Zealand have been training with a 16-hour shift limit since 1985, without needing a longer training program."
Dr. Mark L. Friedell, an ACS Fellow and president of the Association of Program Directors in Surgery, suggested that the fourth year of medical school could be used to prepare students for surgical residency. Dr. Sachdeva said that the ACS is working with other organizations to develop a surgery "boot camp" for fourth-year medical students.
Another helpful alternative would be to develop a "milestone" for first-year residents that might make the ACGME feel comfortable in letting them work 24 consecutive hours, like other residents, said Dr. Friedell, who directs the residency program in general surgery at Orlando Health, a network of hospitals.
Reports from five residency programs on their experience thus far with duty-hour restrictions suggest that surgery interns now are working 6 days/week, and "golden weekends" have disappeared. Patient hand-offs have increased in many programs. Faculty and senior residents are under more stress as more of the workload shifts to them. Many programs have hired additional nurse practitioners and physician assistants to help handle the work residents no longer do.
First-year residents report that they do not feel blamed for the restrictions, but many feel they are being shortchanged by not having the same duty hours as other residents, Dr. Friedell said.
"Part of the reason we're in the mess we're in is because we didn't pay enough attention to what residents did in the pre-80-hour era," said Dr. Joshua M.V. Mammen, assistant professor at the University of Kansas, Kansas City, and past chair of the ACS Resident and Associate Society (RAS). He echoed a theme suggesting that enhanced supervision of residents -- rather than limiting duty hours -- is the key to safe practice.
In a 2006 Internet-based survey of RAS members, approximately 60% said that, ideally, residents should work less than 80 hours/week, and 40% favored more than 80 hours/week, said Dr. Mammen. In an ongoing survey of current RAS members with 841 respondents so far, it's more of a 50-50 split, he said. In all, 48% said that residents should work 60-80 hours/week, 47% believed 61-100 hours/week would be ideal, 2% favored fewer than 60 hours/week, and 3% wanted residents working more than 100 hours/week.
The speakers had no conflicts.
SAN FRANCISCO -- The American College of Surgeons could consider taking over resident training from the Accreditation Council of Graduate Medical Education to avoid the council's latest duty-hour restrictions, which went into effect in July.
In considering strategies to address the unwelcome restrictions, "we haven't taken anything off the table," said Dr. L.D. Britt, immediate past president of the American College of Surgeons (ACS) and chair of the ACS Task Force on Resident Duty Hours. "We shouldn't allow any entity to destroy our training programs."
At least one College official later said the College has no plans to take over accreditation of residency programs, but the mere mention of this possibility as an option drew cheers at an emotional, standing-room-only session on resident duty hours during the annual Clinical Congress of the American College of Surgeons.
Dr. Britt and a panel of ACS leaders described their efforts thus far to modify the new duty-hour requirements before and after they went into effect. The session was the first time surgeons had gathered in large numbers since the new rules went into effect, and many of them vented their frustrations.
They objected most to the 16-hours/day limit on first-year residents. "The 16-hour day is an enemy to education," said Dr. Britt, an ACS Fellow and Brickhouse Professor of Surgery and Chairman at Eastern Virginia Medical School, Norfolk.
Limitations on the work hours of surgical trainees in England, Switzerland, and other European countries have been "devastating" to the quality of education there, he said. "Why aren't they looking at the international experience?" Dr. Britt asked in a lengthy discussion session after the formal presentations.
He and others emphasized that there are no data showing that reduced hours lead to better patient outcomes. On the contrary, the limits could hurt patients by increasing the risk for errors because the new schedule leads to an increased number of patient hand-offs and gives residents less experience, they suggested.
Dr. Ajit K. Sachdeva, an ACS Fellow, director of the ACS Division of Education, and moderator of the session, said in a phone interview afterward that there has been "a lot of chatter" on ACS listservs about the duty-hour restrictions, but the ACS "has no plans" to take over residency program accreditations.
"There's a prevailing sense in the surgical community that the 16 hours a day is not going to be good for surgical training and actually will do harm, because you will have less well-trained people in the future," said Dr. Sachdeva, adjunct professor of surgery at Northwestern University, Chicago. The ACS will continue to try to get the Accreditation Council of Graduate Medical Education (ACGME) to expand the daily 16-hour limit for first-year residents and to keep the 80-hour weekly limit from shrinking.
Under the 2011 regulations, residents must break the rules to get needed experience in continuity of care, said Dr. Thomas V. Whalen, an ACS Fellow and chief medical officer, department of surgery, Lehigh Valley Health Network, Allentown, Pa.
Dr. Whalen, who served on the ACGME task force that reviewed and revised the 2003 regulations, said that pressure for tighter limits on resident duty hours came largely from sleep scientists such as Dr. Charles A. Czeisler, professor and director of the division of sleep medicine, Harvard University, and chief of the division of sleep medicine at Brigham and Women's Hospital, Boston.
Dr. Czeisler said in an interview that he is an advocate of patient safety and evidence-based medicine. "In fact, this year is the 40th anniversary of the first study demonstrating that extended-duration shifts double the rate of errors that interns make when detecting cardiac arrhythmias," he said. Since then, his research has shown that work shifts longer than 24 hours lead to a 460% increase in serious diagnostic mistakes made by resident physicians caring for critically ill patients in the ICU, a 73% increase in the risk of percutaneous injuries, and a 168% increase in the odds of a resident being in a motor vehicle crash while driving home, among other adverse consequences.
An Institute of Medicine (IOM) consensus statement in December 2008 recommended, among other things, that 5 hours of sleep be allowed after any shift longer than 16 hours, and that this sleep time be counted toward the 80-hour/week limit, averaged over 4 weeks.
The ACS published a detailed response to the IOM report, arguing that the 16 hours/day limit "is entirely unworkable in the surgical environment" (Surgery 2009;146:398-409).
The ACGME rules don't go as far as the IOM recommendations because the ACGME applied the 16 hours/day limit only to interns and not to other residents, Dr. Czeisler has noted in previously published statements.
Limiting duty shifts for surgical residents will not necessarily hurt the quality of education or increase the number of years of training needed, according to Dr. Czeisler. He pointed out that "surgeons in New Zealand have been training with a 16-hour shift limit since 1985, without needing a longer training program."
Dr. Mark L. Friedell, an ACS Fellow and president of the Association of Program Directors in Surgery, suggested that the fourth year of medical school could be used to prepare students for surgical residency. Dr. Sachdeva said that the ACS is working with other organizations to develop a surgery "boot camp" for fourth-year medical students.
Another helpful alternative would be to develop a "milestone" for first-year residents that might make the ACGME feel comfortable in letting them work 24 consecutive hours, like other residents, said Dr. Friedell, who directs the residency program in general surgery at Orlando Health, a network of hospitals.
Reports from five residency programs on their experience thus far with duty-hour restrictions suggest that surgery interns now are working 6 days/week, and "golden weekends" have disappeared. Patient hand-offs have increased in many programs. Faculty and senior residents are under more stress as more of the workload shifts to them. Many programs have hired additional nurse practitioners and physician assistants to help handle the work residents no longer do.
First-year residents report that they do not feel blamed for the restrictions, but many feel they are being shortchanged by not having the same duty hours as other residents, Dr. Friedell said.
"Part of the reason we're in the mess we're in is because we didn't pay enough attention to what residents did in the pre-80-hour era," said Dr. Joshua M.V. Mammen, assistant professor at the University of Kansas, Kansas City, and past chair of the ACS Resident and Associate Society (RAS). He echoed a theme suggesting that enhanced supervision of residents -- rather than limiting duty hours -- is the key to safe practice.
In a 2006 Internet-based survey of RAS members, approximately 60% said that, ideally, residents should work less than 80 hours/week, and 40% favored more than 80 hours/week, said Dr. Mammen. In an ongoing survey of current RAS members with 841 respondents so far, it's more of a 50-50 split, he said. In all, 48% said that residents should work 60-80 hours/week, 47% believed 61-100 hours/week would be ideal, 2% favored fewer than 60 hours/week, and 3% wanted residents working more than 100 hours/week.
The speakers had no conflicts.