[originally by Jeff Jarvis]
I'm usually quick to disregard older physicians, particularly surgeons (no offense, Nat) when they say residents are just whining. However, there was a surgeon who testified at the AMA reference committee that offered something that struck me as a valid criticism. Most of the proposals include a cap, either 12 or 14 hours in a single day, over which duty time must be considered on-call hours. All also have a cap on on-call hours.
His comment was about those surgeries that are very long. He mentioned that he frequently did 14 or 15 hour surgeries and wanted to know how residents were going to become qualified at those types of procedures with such a cap.
Anyway, it made me thing. Unfortunately, it didn't really give me any answers.
[originally by Jeff Jarvis]
You’re right, Jeff, the devil’s going to be in the details and they are going to have to do some creative thinking (that will be interesting to witness; some of these programs stirke me as truly hide-bound).
Can you explain the difference between “duty time” and “on-call hours”? I didn’t realize that a program would make a distinction - I thought that you’d probably end up doing two 7am - 7 am shifts per week, with your other days averaging between 10-12? In reading your description of the surgeon’s concern, I am worrying that I’ve missed something really basic - like we are going to be limited to 80 ON CALL hours but number of TOTAL hours per week will be 130 or something!!! (I am confused; obviously have vacation brain - mmmmmm headed to the beach soon … ) In the example you cite, couldn’t a surgical resident participate in those 15 hr surgeries on their long days - or perhaps stay on to complete the surgery but then not be expected to show up for morning rounds?
What I do object to is this running around like chickens with their heads cut off - “The sky is falling! The sky is falling!” when, unless I am missing something very basic, this is a logistical staffing problem, not a huge philosophical issue. Yeah, it’s a thorny logistical staffing problem, I’ll admit, but geez get the guy who did the complicated travel schedules for my daughter’s skating team trips last year to put together the schedule (he was career Army and #### could he do a schedule), and he’d have everyone whipped into shape in no time. Like I said, maybe I’m missing something but scheduling just does not seem like rocket science to me.
Mary in Virginia
MS-III, GWU SOM
Never Give Up! Never Surrender!
Here's my admittedly limited understanding. There will be a total cap on hours at either 80 or 84. There will also be an absolute cap on a 12 or 14 hour day in 'critical care areas', most commonly described as the ED and ICU, although I would certainly include the OR there. There will also be a limit of call no more than every 3rd day. So, the prolonged surgery, if it exceeded the daily cap (assuming someone decides that the OR is a critical care area), would become part of call. This would then interfere with other scheduling because of the q3 thing.
Or something like that. I'll dig around for the actual wording and get back. I've really been focusing on the CSA issue since it effects me prior to the resident work hour issue.
Here is the reference committee recommendations on the resident work hour issue. This is analogous to what I posted on the CSA issue. The source URL is the same.
COUNCIL ON MEDICAL EDUCATION REPORT 9 - RESIDENT PHYSICIAN WORKING CONDITIONS
RESOLUTION 310 - RESIDENT WORK HOURS
RESOLUTION 317 - RESIDENT PHYSICIAN WORK HOURS
RESOLUTION 318 - RESIDENT WORK HOUR STANDARDS
RESOLUTION 321 - RESIDENT/FELLOW WORK AND LEARNING ENVIRONMENT
Mr. Speaker, your Reference Committee recommends that the following recommendations in Council on Medical Education Report 9 be amended by deletion to read as follows:
1. That our American Medical Association adopt the following
definitions for resident physician education:
“Total duty hours” represents those scheduled hours of activity associated with a residency program and include:
a) scheduled time providing direct patient care or supervised patient care that contributes to the ability of the resident physician to meet educational goals and objectives;
b) scheduled time to participate in formal
c) scheduled time providing administrative and patient care services of limited or no educational value, and
d) time needed to transfer the care of patients.
“Work hours” includes all those activities described under duty hours as well as scheduled time performing any work outside of the residency program. This includes among other scheduled activities time spent in patient care (moonlighting), whether or not compensation is received.
“Work-free intervals” are those times in which no scheduled work occurs and are used for rest, recreation, personal and family obligations.
“Organized educational activities” are of two types:
(a) “Formal educational activities” include scheduled educational programs such as conferences, seminars, and grand rounds and
(b) “Patient care educational activities” include individualized instruction with a more senior resident or attending physician and teaching rounds with an attending physician. (New HOD Policy)
2. That resident physician total duty hours must not exceed 80 hours per week, averaged over a two-week period and that our AMA work with GME accrediting bodies to determine if an increase of 5% may be appropriate for some training programs. (New HOD Policy)
3. That workdays that exceed 12 hours are defined as on- call. (New HOD Policy)
4. That scheduled on-call assignments should not exceed 24 hours. Residents may remain on-duty for up to 30 hours to complete the transfer of care, patient follow-up, and education; however, residents may not be assigned new patients, cross-coverage of other providers’ patients, or continuity clinic during that time. (New HOD Policy)
5. That on-call be no more frequent than every third night and there be at least one consecutive 24-hour duty-free period every seven days both averaged over a two-week period. (New HOD Policy)
6. That on-call from home be counted in the calculation of total duty hours and on-call frequency if the resident physician can routinely expect to get less than eight hours of sleep. (New HOD Policy)
7. That assignments in high-intensity settings such as the
emergency department must not exceed 12 scheduled hours. (New HOD Policy)
8. That there should be a duty-free interval of at least 10 hours prior to returning to duty. (New HOD Policy)
9. That limits on total duty hours must not adversely impact
resident physician participation in the organized educational activities of the residency program. Formal educational activities must be scheduled and available within total duty hour limits for all resident physicians for at least eight hours per week averaged over a two-week period. (New HOD Policy)
10. That scheduled time providing patient care services of limited or no educational value be minimized. (New HOD Policy)
11. That program directors should establish guidelines for scheduled work outside of the residency program, such as moonlighting, and must approve and monitor that work. (New HOD Policy)
12. That as continued evidence is developed and collected regarding resident work hours, patient safety, resident well-being, and resident education, resident physician total duty hours be reassessed. (Directive to Take Action)
13. That our AMA commend the efforts of the Accreditation Council for Graduate Medical Education (ACGME) in making significant progress on the issue of resident physician duty hours at their meeting of June 11, 2002. (Directive to Take Action)
Mr. Speaker, your Reference Committee recommends a new final recommendation to read as follows:
That our AMA:
a) strongly encourage the Accreditation Council for Graduate Medical Education (ACGME) to vigorously enforce the common
accreditation standards adopted by their Board of Directors on June 11, 2002 regarding resident duty hours and b) that the ACGME be requested to provide the AMA with a report on the number of programs by specialty that were required to provide immediate progress reports to Residency Review Committees and the Institutional Review Committee as well as the number of programs for which resident surveys and focused follow-up visits were conducted, beginning with the period of July 1, 2001-June 30, 2002 and then on an annual basis. (Directive to Take Action)
Mr. Speaker, your Reference Committee recommends that the
recommendations in Council on Medical Education Report 9 be renumbered according to the adopted recommendations.
Mr. Speaker, your Reference Committee recommends that the
recommendations in Council on Medical Education Report 9 be adopted as amended in lieu of Resolutions 310, 317, 318, and 321 and that the remainder of the report be filed.
HOD ACTION: Recommendations contained in Council on Medical Education Report 9 adopted as amended in lieu of Resolutions 310, 317, 318 and 321, remainder of report filed.
Council on Medical Education Report 9, Resident Physician Working Conditions, specifically addresses the working conditions of resident physicians as they relate to time commitments. The report also establishes definitions of duty hours, work hours, on-call and rest time. The report proposes a system of limits for time commitments that is based on a review of both existing scientific evidence and current proposals from a variety of groups.
Resolution 310, Resident Work Hours, introduced by the New York Delegation, asks our AMA to support reasonable regulations on resident work hours/conditions and that AMA adopt a policy acknowledging that organized medicine must take a leadership role in crafting regulations so as not to adversely impact on the educational mission of residency programs or on patient care.
Resolution 317, Resident Physician Work Hours, introduced by the Illinois Delegation, asks our AMA to support limitations on the number of hours resident physicians may work each week and that AMA reaffirm efforts in support of limitations on resident physician work hours and expand its advocacy with regard to work conditions in graduate medical
Resolution 318, Resident Work Hour Standards, introduced by the Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island and Vermont Delegations, asks our AMA to acknowledge that resident work hour excesses result in decreased quality of patient care and resident health, safety and well-being. The resolution also asks our AMA to
encourage all residency program directors to adopt specific work hour standards.<b
Resolution 321, Resident/Fellow Work and Learning Environment, introduced by the Resident and Fellow Section and the Medical Student Section, asks our AMA to define resident duty hours as those associated with primary resident or fellowship responsibilities and further recommends specific time limits regarding working conditions and enforcement of those limits.
Your Reference Committee heard considerable testimony supporting the need for our AMA to establish policy on resident physician working conditions. There was detailed discussion of several aspects of the duty hour limits proposed in the report. The restriction on assignments in high-intensity settings was identified as being difficult to apply. In light of the fact that such assignments are already controlled by
regulations of the Residency Review Committee in Emergency Medicine, the Reference Committee agreed that this item should be deleted. While the actions of the ACGME on June 11, 2002 were considered to be positive, testimony suggested that the standards have not yet been implemented and that it was premature to commend the ACGME for its work. Much
discussion centered on the need for enforcement of recommendations for limits on duty hours. Significant problems were identified with the proposal to utilize the Joint Commission on Healthcare Organizations as an enforcement agency. In lieu of that option, it was considered most
effective to work with the ACGME and to request a detailed accounting of enforcement activities. After lengthy discussion, the Reference Committee decided to delete the definitions of work hours and work-free intervals.
OK, here is some of the stuff I found. First, here is the URL for my source (note that it is directly from the source, the ACGME or the only folks who have actually passed something more or less enforceable):
* Residents must not be scheduled for more than 80 duty hours per week, averaged over a four-week period, with the provision that individual programs may apply to their sponsoring institution’s Graduate Medical Education Committee (GMEC) for an increase in this limit of up to 10 percent, if they can provide a sound educational rationale;
* One day in seven free of patient care responsibilities, averaged over a four-week period;
* Call no more frequently than every third night, averaged over a four-week period;
* A 24-hour limit on on-call duty, with an added period of up to 6 hours for inpatient and outpatient continuity and transfer of care, educational debriefing and didactic activities; no new patients may be accepted after 24 hours;
* A 10-hour minimum rest period should be provided between duty periods; and
* When residents take call from home and are called into the hospital, the time spent in the hospital must be counted toward the weekly duty hour limit.
The whole report is 9 pages and I don’t have time to read it all right now. I’ll try to give it a shot later tonight.
Also, here is another URL that are relevant:
The AMA page on this issue: