Let First-Year Residents Work Longer Shifts, ACGME Proposes

November 04, 2016

First-year residents would no longer be limited to 16-hour shifts during the 2017-2018 academic year under a controversial proposal released today by the Accreditation Council for Graduate Medical Education (ACGME).

Instead, individual residency programs could assign first-year trainees to shifts as long as 28 hours, the current limit for all other residents. The 28-hour maximum includes 4 transitional hours that's designed in part to help residents manage patient-care handoffs.

The plan to revise training requirements does not change other rules designed to protect all residents from overwork. The maximum number of hours that they can log each week remains at 80. All residents must have at least 1 day in 7 free from both clinical experience and education. And in-house call can't be more than every third night. All these limits are based on 4-week averages.

The ACGME capped the shifts of first-year residents at 16 hours in 2011 as a part of an ongoing effort to make trainee schedules more humane and avoid clinical errors caused by sleep deprivation. Some medical educators and medical societies claim, however, that this particular reform has worsened the learning experience of first-year residents as well as continuity of patient care.

ACGME CEO Thomas Nasca, MD, told Medscape Medical News that the problem arises largely from first-year residents not being on the same schedule as supervising residents and others on their "home" educational team. On a 16-hour clock, first-year residents can end up working under relative strangers, said Dr Nasca. "The lack of synchronization is very disruptive."

The solution, he said, is putting everyone on the same clock.

And it's a safe solution for residents and patients alike, according to the ACGME. The group touts a study published in the New England Journal of Medicine in February showing that longer shifts and less rest in between for surgical residents did not affect the rate of serious complications or surgical fatalities. Residents working longer shifts were no more dissatisfied with their overall well-being than those whose shifts were capped in accordance with AGME standards. They indicated that their educational experience improved, but at the expense of personal time. The study, called Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST), encompassed 117 general surgery residency programs in 151 hospitals.

"A Dangerous Step Backward"

Not everyone buys these findings and the arguments for relaxing the 16-hour rule for first-year residents. Both the American Medical Student Association and the Committee of Interns and Residents, a union representing 14,000 physicians, oppose the AGCME proposal. The consumer watchdog group Public Citizen calls it "a dangerous step backward."

"Study after study shows that sleep-deprived residents are a danger to themselves, their patients, and the public," said Michael Carome, MD, director of Public Citizen's Health Research Group, in a news release. "It's disheartening to see the ACGME cave to pressure from organized medicine and let their misguided wishes trump public health."

Public Citizen says it has public opinion on its side. A recent poll commissioned by the group showed that 86% of Americans oppose lifting the 16-hour cap on the shifts of rookie residents.

Public Citizen also looks askance at the FIRST trial, funded in part by the ACGME. It accuses the study of neglecting to obtain informed consent from trainees and patients. To Dr Carome, the study conveniently arrived at the conclusions that its authors set out to reach.

For his part, Dr Nasca said the ACGME made a good-faith effort to arrive at a consensus decision by listening to specialty societies, certifying boards, patient safety organizations, and residents. And rather than ignoring the well-being of first-year trainees, he said, the plan would step up efforts to prevent burnout and depression. It calls on residency programs, for example, to ensure that trainees can make appointments with a physician or a mental health professional, even during their working hours. And faculty and residents must be trained to identify symptoms of burnout, depression, and substance abuse.

The ACGME proposal will go to the group's board of directors for a final decision after a 45-day comment period. More information on the proposal is available for download from the ACGME.

Follow Robert Lowes on Twitter @LowesRobert

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