What do we do with the IOM recommendations?
It’s the giving time of year, and the Institute of Medicine (IOM) has not disappointed. The IOM’s report on resident duty hours isn’t the gift that I was hoping for this holiday season, but sometimes you just need to play the hand you are dealt.
For anyone not familiar with these recommendations, I’ll share the key points:
• There must be protected sleep time (5 hours, somewhere between 10PM and 8AM) in 30 hour shifts, with only 16 of those hours being admitting hours (down from 24 hours presently). If there is no protected sleep period, the maximum shift length becomes 16 hours.
• Maximum in-house call becomes every third night, without averaging.
• Residents must continue to have a minimum of 10 hours off after a day shift (rather than any shift), but now must also have 12 hours off following a night shift, and 14 hours off after any extended duty (30 hours).
• Night float is limited to four consecutive nights. Following three or four consecutive nights, residents must have 48 hours off.
• Residents will have five days off per month, including one 48-hour period off per month.
• All moonlighting (including external) counts against the 80-hour weekly limit.
No change is suggested to the present 80-hour averaged rule.
I want to make a couple of quick points. First, I’m not going to use this space to pass judgment on the IOM recommendations. I was a resident in the mid-1990s before the world of duty hour restrictions and admission caps. I recognize that having fatigued residents caring for sick patients is not a recipe for success. Some moderation and limitation in terms of work was, and is, necessary.
We need to recognize that these recommendations are just that– recommendations. There remains plenty of time and opportunity for healthy debate regarding potential adjustments to the existing ACGME duty hour rules. There has already been active discussion on the Association of Program Directors in Internal Medicine listserv, and I’m certain this topic has come up in many other venues.
So…what the heck do we do with these recommendations? Well, in my program, we are already having discussions regarding the potential changes we will need to make if any/all of these recommendations are enacted by the ACGME. I am certain we are not the only program having these discussions.
I think we need to work under the assumption that these recommendations will be enacted in some way, shape or form. The IOM is like E.F. Hutton– when they talk, people listen. The IOM’s track record is a good one. Although uncomfortable, forcing us to look in the mirror might not be the worst thing for our patients or our programs.
The other thing we can do is contribute to a healthy discussion on this topic. Let’s hear your thoughts regarding some of the following:
• What do your residents think about these recommendations, particularly the potential impact on patient continuity and educational opportunities?
• What do you think of these recommendations?
• Do you have mechanisms in place (i.e., hospitalist programs) that will allow your institution to meet these potential changes? What is the potential fiscal impact (tough time for any of us to ask for additional funding)?
• How much will your program have to change if these recommendations are enacted?
Those are just some initial questions to spur some discussion. I would love to hear any comments you have on these recommendations, and I know we’ll be having continued discussion about this in the coming months.
On an equally important note, I wish each and every one of you reading this a wonderful holiday (Merry Christmas for me, but whatever holiday you may celebrate, I wish you a good one) and a very happy and healthy New Year. I’ll talk with you in 2009!
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Michael Pistoria, DO, FACP
Michael Pistoria, DO, FACP is associate program director for internal medicine at Lehigh Valley Hospital (LVH) in Allentown, PA. He received his BS in Molecular Biology from Vanderbilt University, and his DO degree from the Philadelphia College of Osteopathic Medicine. Dr. Pistoria is a charter member of the Society of Hospital Medicine, has served on the Education Committee since 2000 and has presented nationally regarding hospitalists and medical education. He completed his residency training, including a chief resident year, at LVH and joined the staff there as a hospitalist in 1999.Michael has written 3 posts.
Comments
Dr. Pistoria,
I am the Administrative Director for GME at Arrowhead Regional Medical Center. Thank you for your analysis. Our residents are just starting to analyze and digest these hour recommendations. We are working on our next years schedule to comply with the recommendations, so not sure how it will impact our programs yet.
On a different subject, I noticed you are a DO, are you involved in teaching DO residents? We have both AOA and ACGME residents at ARMC, and it proves to be a challenge in the operation and interpretation of the standards. Do you have any thoughts you could share?
Thank you.
Thanks for your commentary on this. One of the problems my program has faced with the current restrictions is an effect on procedural numbers, which are the core of our re-accreditation in Ob/Gyn. We handled much of the previous work-hour limitation policy by starting a night shift rotation and adding one resident per year. If we have to carve up their shifts into smaller (but probably more) blocks – especially in regards to the rule of no more than 4 night shifts in a row – I believe it will further impact the numerical experience because of losing exposure to the scheduled surgical cases that happen mainly 7 AM to 3 PM.
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