ACGME Won't Extend Resident Shifts in 2016-2017

May 23, 2016

Residents won't log longer shifts in the 2016-2017 academic year now that the Accreditation Council for Graduate Medical Education (ACGME) is taking more time to develop a proposal that may loosen current work rules.

In announcing the delay on May 17, ACGME Chief Executive Officer Thomas Nasca, MD, also said that his group has approved extending and expanding a controversial study on longer shifts for general surgery residents through 2016-2017.

That study, the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST), was funded by the ACGME, the American College of Surgeons (ACS), and the American Board of Surgery. In February, the New England Journal of Medicine (NEJM) published the results of FIRST from the 2014-2015 academic year. They showed that longer shifts and less rest in between did not affect the rate of surgical fatalities or serious complications.

Residents working longer shifts indicated that their educational experience improved, but at the expense of time with friends and family, extracurricular activities, rest, and health. However, these residents generally were no more dissatisfied with their overall well-being than residents whose shifts conformed to the more lifestyle-friendly ACGME rules, the study shows.

Trial organizers had hoped that the study would result in more relaxed ACGME work rules that could take effect in 2016-2017. However, Dr Nasca said in a letter addressed to the "graduate medical education community" that it would be "premature" to propose any modification to duty-hour rules in the upcoming academic year. He said that an ACGME task force on duty hours intends to complete its study of the subject before recommending changes and soliciting public feedback.

Public Citizen Decries Lack of Informed Consent

Since 2003, the ACGME has placed limits on resident hours to protect patients from the mistakes of sleepy trainees, and to protect the trainees themselves from the risks of overwork — needle sticks, depression, car wrecks driving home. The most notable of these restrictions is the maximum number of hours a resident can work each week — 80 hours, as averaged over 4 weeks. In addition, residents must have at least 1 day off every 7 days, and not be on call more than every third night. These restrictions are not under debate.

However, groups such as the ACS have contended that shorter shifts mandated by the ACGME have harmed continuity of care by requiring more patient hand-offs. And in the process, training has suffered because residents sometimes can't see a case — or a given procedure — to the end, the argument goes. Under current ACGME requirements, first-year residents may not work more than 16 hours straight, while shifts for all other residents must not exceed 28 hours, which includes a 4-hour transition. And all residents must have at least 8 hours off, and ideally 10, between shifts, and at least 14 hours off after working continuously for 24 hours.

FIRST was organized to see whether longer shifts and short rest periods were really that detrimental to patient care and resident well-being. It consisted of 117 general surgery residency programs in 151 hospitals, which included Johns Hopkins Hospital in Baltimore, Maryland, the Mayo Clinic Hospital in Rochester, Minnesota, and Massachusetts General Hospital in Boston. In roughly half of the programs, shifts could exceed the maximums set for first-year residents and all others, and rest periods could be shorter than required. However, all other ACGME rules, including the 80-hour week, remained in force.

The consumer watchdog group Public Citizen says that FIRST and a similar trial involving internal medicine residents are unethical because researchers did not obtain informed consent from trainees or patients, who were put in harm's way. The American Medical Student Association, which includes residents, has joined in the criticism.

In the case of FIRST, the institutional review board of Northwestern University in Evanston, Illinois, home to principal investigator Karl Bilimoria, MD, had exempted the study from the usual consent protocols because the study randomly assigned hospitals and their residency programs, not trainees and patients. FIRST was not deemed "human subjects research."

The news that FIRST would continue through the 2016-2017 academic year drew additional reproach from Public Citizen. Michael Carome, MD, director of its Health Research Group, said in a news release that the ACGME's decision to green-light the study extension "represents a serious failure of moral leadership." However, Dr Carome expressed relief that the ACGME would not be relaxing restriction on duty hours in the coming academic year.

"We strongly oppose any such action, now or in the future, because a substantial body of evidence demonstrates that sleep deprivation caused by resident shifts lasting more than 24 or more hours threatens the health and welfare of both residents and their patients," he said.

FIRST Could Extend to More Than Half of General Surgery Programs

Although the NEJM article confined itself to FIRST results from the 2014-2015 academic year, the study continued through 2015-2016. Now FIRST will extend into the coming academic year, and expand as well. Dr Bilimoria, a professor of surgery at Northwestern University, told Medscape Medical News that as many as 30 additional residency programs may join the trial.

As with current participants, roughly half of the new residency programs will be randomly assigned to a group that follows ACGME policy. The other half, in the "flexible-policy group," will extend work shifts and reduce rest periods in between.

There are 262 general-surgery residency programs accredited by the ACGME. If FIRST grows as much as Dr Bilimoria anticipates, it would cover more than half of the programs in the nation.

The study's methodology will essentially remain the same in the 2016-2017 academic year, Dr Bilimoria said. However, researchers will pose additional questions to residents "to drill down on different aspects of resident well-being, burnout, and fatigue."

Although FIRST found that longer shifts produced more lifestyle grumbles, "residents are overwhelmingly in favor of moving toward flexibility in duty hours," he said. He cited the embrace of the FIRST findings by the Resident and Associate Society of the ACS. That group said in a news release that "flexibility in duty hours is not only safely possible, it is essential to provide surgical residents with exposure to the variety and complexity of educational experiences necessary to become fully trained and competent surgeons."

Added Dr Bilimoria: "The overall surgical community generally has believed since 2003 that duty-hour restrictions were problematic."

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