Patient Safety Advocates Give Plan to Reform Medical Residency a Failing Grade

Accreditation Group’s Proposal on Resident Physician WorkHours Do Not Measure Up to Institute of Medicine Recommendations

Summary: As regular HealthBeat readers know, resident sometimes work 30 hours shifts. In 2008, the Institute of Medicine (IOM) recommended capping shifts at 16 hours, saying that longer shifts are unsafe for patients and residents themselves. Sleep deprivation is likely to lead to errors; residents acknowledge that lack of sleep has caused them to make mistakes that harm, and sometimes even kill patients. Exhaustion also affects how they feel about their patients. I have posted about this here. The IOM also noted that in some cases, residents need better supervision. I told the story of what happened to 15-year-old Lewis Blackman earlier this month.


The Accreditation Council on Graduate Medical Education (ACGME), the group that oversees the training of physicians has been reviewing the IOM recommendations since 2008.  Yesterday, the ACGME finally issued its report.

Below a press release issued by a coalition of patient safety groups, commenting on the ACGME’s proposals.

WASHINGTON, D.C. – The coalition of public interest and patient safety groups that have spearheaded the www.WakeUpDoctor.org campaign issued a “report card” in response to today’s proposal by the Accreditation Council on Graduate Medical Education (ACGME) to restructure medical residency programs, published in The New England Journal of Medicine

Since February, the Wake Up Doctor campaign has been instrumental in raising awareness about the dangers posed by medical residents working shifts as long as 30 hours, frequently with limited support or supervision, leaving them exhausted and prone to mistakes. The coalition, which includes Public Citizen, Mothers Against Medical Error and other patient advocates, based their grades on the landmark 2008 report by the Institute of Medicine (IOM), Resident Duty Hours: Enhancing Sleep, Supervision and Safety. The IOM report made a thorough review of issues related to residency and listed 10 recommendations for change, including an increase in supervision of junior residents and a significant reduction in work hours.

Although ACGME, the group responsible for training physicians in the United States, demonstrated some progress in reconciling its regulations with the mounting body of scientific evidence linking acute and chronic sleep deprivation with preventable medical errors, the coalition judged that the proposal fails compared to the more comprehensive recommendations of the IOM report.

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Common Sense Limits on Resident Duty Hours
Grade:  F

The IOM report called for a reduction in resident duty hours from 30 consecutive-hour shifts to continuous shifts lasting no longer than 16 hours. The ACGME’s proposal implements that change only for medical residents in their first year (interns). This change would therefore only apply to 22 percent of total residents in hospitals throughout the country. Most medical residents could continue to be scheduled for a maximum of 24 consecutive hours, a duration rejected by the IOM in late 2008. Ample evidence has shown that marathon shifts in excess of 16 hours can have a detrimental effect on a physician’s abilities and judgment.

Additionally, the IOM made a number of recommendations ranging from the minimum time off between scheduled duty periods, the maximum number of consecutive nights a resident may work night duty, adjustments to the minimum amount of time off per week, and an immediate, urgent requirement for hospitals to provide safe transportation home for fatigued residents. Nearly all of these recommendations are left out of the ACGME’s proposal.
 
“Although it’s a positive step for the ACGME to make any acknowledgment of the evidence linking resident fatigue and medical error, their proposed solution misses the mark,” said Dr. Alex Blum, one of the authors of the recent study, “US public opinion regarding proposed limits on resident physician work hours” which was published in BMC Medicine.  “It's both common sense and supported by data that physicians do not cease to be human beings when they complete their first year of residency, nor does an additional year of training make them impervious to the physiological effects of sleep deprivation. Our research shows that patients want to know when their physician has worked a marathon shift and the vast majority would request another physician. The ACGME’s proposals don't move us towards transparency.”

Adequate Direct, Onsite Supervision
Grade:  B

The IOM report called for first-year residents not to be “on duty without having immediate access to a residency program-approved supervisory physician in-house” (Summary, p.13).  The ACGME adopts this measure, but only somewhat vaguely addresses the IOM report’s recommendation for measurable standards of supervision for each level of residency.

 “The ACGME has taken an important step in regard to supervision of first-year residents and to setting specific standards for different levels of supervision,” said Helen Haskell, founder and president of Mothers Against Medical Error. “I think the acid test will be in the details. We need to be sure that residents of all levels have sufficient backup and reasonable limits on their workloads.”

Structured, Institutionalized Handover Processes
Grade:  C

The IOM report called for medical residents to be trained to communicate clearly and accurately when handing over patients after residents’ shifts end, a process known as “handovers” or “signouts.” The ACGME proposal includes this provision, as well as requiring a system to quickly and accurately communicate to staff and patients the roles and patient responsibilities of both residents and attending physicians at any given time.

However, the IOM report also called for dedicated, protected and overlapping time for patient care teams to conduct these transitions. The ACGME proposal does not include this solution to reduce errors related to handovers and improve team communication among providers.

“Without question, the environment in which handovers take place must be closely monitored to prevent errors and potential harm for our patients,” said Dr. Farbod Raiszadeh, president of the Committee of Interns and Residents/SEIU Healthcare, the nation’s largest union for housestaff. “However, I can say from experience that part of that environment is how long the outgoing resident has been working in the hospital and how fatigued they are at the time of transition. Handovers are safer, more thorough and less prone to error when they occur in hour 16 than in hour 30 of a shift.”

Increased Oversight of Residency Programs
Grade:  F

Although the ACGME plans to dramatically increase the number of site visits, its oversight proposal falls far short of the IOM’s standard. The IOM report called for rigorous oversight on the part of the ACGME, including unannounced visits to teaching hospitals, strengthened complaint procedures and confidential, protected reporting of hours by residents and teaching hospitals – none of which is directly addressed by the ACGME’s proposal. Additionally, the IOM report called for independent monitoring by the Centers for Medicare and Medicaid Services and the Joint Commission – a recommendation that is also absent from the ACGME proposal, thus leaving the major control in the hands of the non-governmental ACGME instead of increasing the role of the government in oversight.

“The improvements in the new ACGME guidelines are largely swamped by the failure to cover the majority of medical residents with the protection of not having to work more than 16 hours continuously,” said Dr. Sidney Wolfe, director of Public Citizen’s Health Research Group. “This is the second revision of ACGME requirements in the last seven years and the organization still does not get it right.”

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The coalition will continue to educate the public concerning the areas where the ACGME proposal fails to meet the standards set by the 2008 IOM report. 

To learn more about the issue of resident work hours, supervision and safety, and to sign the campaign’s letter to the ACGME in supp
ort of the IOM recommendations, visit
www.WakeUpDoctor.org.

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