In announcing its new medical residency standards, the Accreditation Council for Graduate Medical Education touted that the guidelines took a comprehensive approach in defining how doctors-in-training are supervised and educated. But what most observers focused on was the number of hours residents would be allowed on the job.
ACGME work-hour standards win praise
It appears that healthcare industry executives are fine with the ACGME's decisions. The new standards retain the 80-hour workweek limit (averaged over four weeks) that was established in 2003, and all but first-year residents will still be allowed to work 24 consecutive hours—though second- and third-year residents must have 14 work-free hours after a 24-hour shift. First-year residents can work a maximum of only 16 hours in a row. It's recommended that senior residents get eight hours off between shifts, but this is not required.
Exemptions can be made to allow up to 88 hours of weekly duty if this workload is “based on a sound education rationale,” the standards state. Also, “on their own initiative,” residents can exceed consecutive work-hour limits to provide care to a single patient if continuity of care is required to a severely ill or unstable patient, if events of “academic importance” are transpiring, or to provide “humanistic attention” to a patient or family.
Joanne Conroy, M.D., chief healthcare officer for the Association of American Medical Colleges, says there was a general appreciation for the greater focus in the new standards on fatigue management, teamwork and communication. “It’s all good,” she says. “It’s part of the way we’re changing the practice of medicine.”
The only real disappointment that AAMC member institutions had was that they were asking for another year to implement the new standards, she says. “Many institutions were pushing for a 2012 start time, but they are very aware of the public perception and demand to do this sooner rather than later,” Conroy says.
The standards go in effect July 1, 2011. And, according to ACGME CEO Thomas Nasca, M.D., the cost of implementing these standards nationwide will be $380 million (in 2008 dollars) the first year and then about $330 million for each year after that—or about $32 per hospital admission.
While the standards are expected to require additional staffing—such as the hiring of physician assistants, nurse practitioners and other “physician extenders”—Nasca says the biggest expenses will be providing transportation home for night-call residents who are too tired to drive safely and the implementation of structural procedures for the handoff of care for individual patients between residents coming and going.
Nasca adds that, according to a cost analysis of the new standards conducted by researchers at UCLA and the RAND Corp., there could be a cost benefit “from a societal perspective,” if these handoff procedures result in a 2.4% reduction in adverse events. For an individual hospital to see a cost benefit, however, Nasca says there would have to be a 10% cut in adverse events occurring during transitions in care.
The cost of implementing the recommendations contained in a 2008 Institute of Medicine report on resident duty hours, which included 16-hour shift limits for all residents and giving residents five days off a month, was estimated at $1.7 billion.
The AAMC’s Conroy says the costs of the new standards, while less than anticipated, were still noteworthy and will also require “some significant re-engineering of the first-year resident experience.”
Nasca says the most feedback the ACGME received was regarding the 16-hour limit for first-year residents, which he described as a “significant change in philosophy and structure.”
He also says analogies between physicians and truck drivers, airline pilots or other jobs with mandated time limits are not “durable,” though he notes that an exception can possibly be made for anesthesiologists, whose job can have long periods requiring low activity but high vigilance. A comparison between physicians, especially those in emergency medicine, could be made to military pilots where there are long hours of high-intensity activity, Nasca explained.
Nasca adds that critics who want stricter limits on residents ignore that—once their training is over—residents enter an environment where there are no set limits, so educators "need to train people to know their limits.”
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