ACGME gives update on duty hour reform

By: Julie McCoy October 29th, 2009

Since the IOM released the report on resident work hours last December, the ACGME has been working hard to address the concerns the IOM raised. After nearly a year of information gathering, ACGME CEO Thomas Nasca, MD released a letter to the GME community giving an update of their efforts.

Over the past year, the ACGME has collected position statements from countless professional organizations, sleep experts, medical educators, the Joint Commission, and several others. It’s also asked for literature reviews on the subjects of sleep and education to determine what work hour reforms, if any are needed.

In the letter, Nasca outlined their findings so far. Note: These are not standards, but they’re the conclusions the organization has drawn so far based on its research. Nasca addresses five main points:

Patient safety. Looks at both direct and indirect dimensions of patient safety and how duty hours have affected both aspects. To ensure patient safety, Nasca says, GME leaders must be sure that oversight and supervision systems will prevent errors made by trainees from reaching patients. Additionally, Nasca says senior residents must be given more authority and responsibility for patient care to better prepare graduate to practice as independent and competent physicians.
One size does not fit all. According to Nasca, “Each specialty has nuanced dimensions of the clinical educational environment that require some flexibility in standards.” One standard for all trainees and all specialties will not work. Understanding how and why different trainees need different work limitations requires a deep understanding of GME, and the Nasca says that this is reason why the ACGME (not the government) must continue to set standards for duty hour limits.
Duty hours limitations has far-reaching affects. Nasca states that duty hours directly affect 13 of the specialties, but the implications of the restrictions affect other specialties as well. “Limits on resident time in surgery have had implications for pathology. Limits on resident time in Medicine and surgery have had major impacts on support for the work of the Emergency Department,” Nasca explained. He also recognized the negative affects work hour limits have had on the faculty, missed educational opportunities for residents, and the engagement of residents in patient care.
Fitness of duty is an issue. Residents are more rested, less stressed, and have time for a life. However, Nasca says that evidence shows residents are not sleeping more. Patient safety cannot rest only on work hour limits. Instead, it is more connected to “fitness of duty” and managing fatigue. To ensure patient safety, Nasca says, “it is the number of hours of sleep that residents are enjoying and the match of the resident’s workload to their level of training that appear to be factors that drive fatigue.”
Absolute rules vs. substantial compliance. Nasca stresses that duty hour compliance must continue to be monitored through the accreditation lens of “substantial compliance” rather than “absolute rule”.

The letter touches on quite a few other topics and gives a good picture of the ACGME’s stance thus far on the main issues and objections the GME community has raised in regards to further restricting the duty hour rules.

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