On July 1, 2003 the Accreditation Council for Graduate Medical Education (ACGME) rolled out new duty hour standards affecting all specialties. These across-the-board common standards did little to impact "business as usual" for some specialties. For others, however, the changes caused a dramatic paradigm shift that still reverberates today.
ACGME is the accrediting agency responsible for overseeing nearly 104,000 residents in 8,200 programs and approximately 700 teaching hospitals nationwide.
"We're the only accrediting body for allopathic medicine," explained Ingrid Philibert, director of field activities for the organization, "so we have a pretty wide reach."
Although participation is voluntary, Philibert said, ACGME accreditation is required if programs wish to receive a portion of the $6 billion in annual federal funding for resident education made available through the Medicare program and for residents and fellows to sit for the American Board of Medical Specialties. The net result is that most medical programs opt to undergo the rigors of the accrediting process.
While ACGME began developing duty hour standards for some specialties as early as the 1980s, the board of directors didn't approve the common standards until February 2003. Philibert, who staffed the workgroup that developed the minimum standards, said at that time there were two strong forces that combined to expedite the process – growing internal concern and public pressure.
"The internal impetus came from an understanding that the work of physicians was becoming much more intense," she said. However, Philibert continued, that alone probably wouldn't have hastened the timeline "if there hadn't been considerable national interest in the topic."
A series of research studies and growing consumer concern voiced by the watchdog group Public Citizen led federal legislators to consider setting national limits on resident hours.
In 2001, Public Citizen, the American Medical Student Association, and the Committee of Interns and Residents petitioned the United States Occupational Safety and Health Administration to monitor resident hours citing post-call motor accidents as a concern. Philibert said OSHA decided they didn't have purview since the petition dealt with accidents outside of the workplace. However, OSHA requested ACGME hasten its quest to regulate duty hours for the protection of both patients and medical personnel.
The result was implementation of an 80-hour work week, "adequate" rest between duty periods, a 24-hour limit on continuous duty time with an additional six hours permitted for patient transfer and continuity of care or for didactic instruction, in-house call limited to one night in three, and one day in seven completely free of all education or clinical duties. Each of these stipulations is averaged over a four-week period, which critics say allows too much leeway for exhausted residents to still be engaged in patient care.
Critics also question the enforcement of the standards. A September 2005 JAMA study found 67.4 percent of interns reported working longer than 30-hour shifts and 43 percent said they worked more than an 80-hour week when averaged over four weeks. It should be noted, however, that the report was based on data collected in the first 11 months after implementation.
Philibert said her organization keeps tabs on duty hours through a variety of mechanisms including confidential surveys of residents, interviews with program directors and educators and a detailed look at resident logs and scheduling during the accreditation and review process.
"Our data suggests that most programs are compliant. Having said that, there are some specialties that have more issues around noncompliance," Philibert stated.
Specialties that had to reduce hours back in 2003 in order to come into compliance tend to be the ones still struggling with the changes; obstetrics/gynecology, general surgery, thoracic surgery and neurosurgery all fall under this heading.
However, Philibert continued, she doesn't see pervasive evidence of noncompliance even within these procedural specialties.
"Last year, we issued about 5,800 citations across all the standards we have and only 210 were related to duty hours," she noted.
Dr. Fred Kirchner, associate dean for graduate medical education at Vanderbilt University School of Medicine in Nashville, oversees 850 residents and clinical fellows participating in the 67 different training programs offered.
"Each program knows best how to keep the tallies, and we trust them to do so," he said of monitoring duty hours. However, he added, "We double check on them, too."
Kirchner noted that at approximately the midway point between ACGME site visits, the university does an internal review of each of the training programs.
"The programs also report to the ACGME annually, and I have to sign off on that … I have to be pretty comfortable that the truth is being told," he said of including his signature on the report.
"It's always hard to change the culture," he added, "but program directors understood what was going on and took it seriously."
However, Kirchner continued, systemic changes are often accompanied by unintended consequences. With the limitation of duty hours, issues tied to patient handoffs have arisen as another impetus to quality care. He said the conundrum becomes, is it better to have a tired doctor who knows the patient or an alert one without the necessary background information? The solution, Kirchner continued, is to try to formalize patient transfers to minimize the loss of key information.
"At Vanderbilt, we're fortunate to have a robust technology system," he said, adding that IT protocols act as a check and balance system. In an effort to break down the hierarchy that tends to exist in medicine, the university also engages in trainings to teach medical personnel at all levels to actively listen to each other and to function as teams. Under such a system any team member is encouraged to speak out if he or she has information to share.
Another issue with the restriction on hours pertains to "shift mentality," according to Kirchner. He said that most physicians rebel against the concept of working a shift. It's natural, he noted, for a resident to want to be around to see the results of an important diagnostic test or to sit in on the consult he or she requested … even if those agenda items happen after the resident has maxed out duty hours for the day.
The flip side, he said, is that you don't really want residents who simply check out and feel like they are no longer responsible for their patient because their shift has ended.
"It's a tough issue, and I don't think we've got it resolved yet."
Kirchner noted that while duty hour reform has been a concern for quite some time, the current national mandates aren't yet four years old.
"It may be second nature a generation from now, but we're in the middle of a sea of change here," he concluded.