Archive for the ‘Residency Training Programs’ Category

July 1 – New Residents, New Rules……Again!

Monday, June 13th, 2011

Last year, I wrote a blog on “The July Effect”, a long-observed phenomenon of increased hospital deaths during the month of July that was substantiated by medical data and statistics just last year. These data seemed to specifically relate these deaths to the influx of new medical school graduates into teaching hospitals as first-year residents of those institutions. The conclusions of the study seemed well-substantiated. I further elaborated on some of the potential causes of errors being made that could result in harm to patients; what I didn’t elaborate upon was the rigorous and demanding schedule that residents assume.

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted new policies regarding the time limitations of ALL residents, but specifically focused on the first year resident. These limitations were placed on the number of hours that residents could and should work in any given week or rotation in an effort to safeguard the health of the resident but more so to ensure the safety and well-being of patients being treated by these residents.

It is now 2011, and the ACGME is instituting even stricter limitations affecting both first year and mid-level residents; Nixon Peabody does a great job of delineating the changes in the guidelines. Much information has been published in the last year regarding the continued occurrence of medical errors despite protocols and safety mechanisms in place to protect patients (click on related blogs below). It seems that the ACGME is attempting to address some of these errors by addressing the fatigue factor of medical and surgical residents in training. The overall maximum hours per week will not change; it remains at 80 hours.  Yes, twice that of “normal” jobs. One big change is the limit on the maximum continuous duty period for first year residents; this will be decreased from 24 to 16 hours.  It will remain 24 hours for residents after their first year, but recommendations include “strategic napping.” Another change is the additional duty time, previously allotted as 6 extra hours to perform clinic duty, transfer of care, didactic training, etc.; for first year residents, these duties are to be included in the overall 80-hour work week, but after the first year, the residents will be allowed 4 additional hours. A third big change is the minimum time off between duty periods. Previously, it was noted that all residents “should have” 10 hours between shifts; year 1′s are still recommended to have 10  hours off, but they MUST HAVE AT LEAST 8! Intermediate-level residents should also have 10 hours off, but they also must have at least 8 hours off with a mandatory 14 hours off if they just completed a 24-hour shift. Final year residents are recommended to receive 8 hours off, but this is still being reviewed.  One thing that has not changed is the mandatory 1 day off in 7, averaged over 4 weeks.

Many of us watch the medical TV shows, but none of these shows really paint the true picture of medical residency training. As a Physician Assistant student, I trained alongside medical residents and medical students, alike. My training mirrored theirs in the hospital setting, and it happened well before the 2003 ACGME recommendations. There were times during my surgery rotation in a trauma center during which I worked 36 hours straight, followed by 10 hours off, then back to 10- and 12-hour days. The working hours entailed clinic time, managing daily in-patient care, many hours in the operating room, admitting patients during the overnight hours from the emergency room and emergency surgery for trauma victims, hours and hours at a time, in the overnight hours and during the day.  By the end of 36 hours, the exhaustion was indescribable. It is easy to understand how and why mistakes happen. After these crazy shifts, no one ever looked so glamorous as those who are depicted on television shows…..TRUST ME!

July 1, 2011, marks the date when over 100,000 medical residents across the USA from ACGME-accredited training programs start their training in teaching hospitals/institutions across this great nation. We should applaud the ACGME for looking at the data, analyzing studies regarding sleep deprivation, and putting forth these guidelines, not only to aid in patient safety but also to protect the health and well-being of these doctors in training. The pressures of residency are incredible. It is interesting that there was and still is opposition to the duty-hour limitations, citing oppositional rationale such as the residents do not learn enough in 16 hours, and small institutions do not have the support staff to treat all of the patients without the addition of medical resident hours.

So, who is going to fill those gaps created by the resident-hour restrictions placed by the ACGME come July 1st? Each institution will have to look at its own hospital model and decide according to current standards. In 2003, many of these gaps were filled by Physician Assistants and Nurse Practitioners; I suspect this will again be the case.  These mid-level practitioners are quite capable of providing many of the services necessary in hospital settings; they are a growing and well-respected addition to the healthcare team, and I suspect that their usefulness and potential will be more fully appreciated with the institution of healthcare reform!

For more information and Frequently Asked Questions (FAQs) regarding the ACGME guidelines, please go to the website and click on the links!

And, no matter who is caring for you or your loved one, never be afraid to ask questions about therapies and medications being ordered. Be informed!

Related Posts:

“The July Effect”: Where To Seek Medical Care When The Heat Is On

Medical Malpractice – Serious Medical Errors: Failure of the System or Just Plain Ignorance

Study Finds Regional Hospitals Often Are Better At Preventing Medical Errors Than Academic Centers – Kaiser Health News

Tort Reform or Just Plain Medical Care Reform: the debate continues as thousands are injured annually in US hospitals

 

 

 

 

 

 

New Changes in Medical Residency Requirements Announced – The Libby Zion Case Lives On.

Tuesday, June 29th, 2010

Putting aside the issue of avoiding the brand new incoming resident staff, which occurs on July 1st of each year, there are much more serious concerns about the fatigue and supervision factors whenever care is entrusted to doctors-in-training – namely, interns (first year medical school graduates) and residents (post-graduate physicians in specialized fields of training). Over the last decade these “concerns” have finally made their way to the organization that governs the training of medical graduates, the Accreditation Council for Graduate Medical Education (ACGME). The central issue, however, has never changed – patient safety.

A landmark lawsuit from New York – the Libby Zion case – brought to the public’s awareness the dangers inherent in these post-graduate training programs.

For those who may not recall, the Libby Zion case involved the death of an 18 year old college freshman, who was taken by her parents to a New York hospital, on October 4, 1984, when she developed a fever of 103 and became agitated. By 6:30 a.m. the next day, Libby Zion was dead. The story is recounted well in a lengthy but highly informative piece entitled “The Doctor is Out.”

It turns out that this young lady was the daughter of Sidney Zion, the newspaper columnist, lawyer, and well-connected New York raconteur. The essential facts of the case are recounted by The Washington Post in a November 2006 article entitled “A Case that Shook Medicine.The sub-heading is perhaps even more noteworthy – “How One Man’s Rage Over His Daughter’s Death Sped Reform of Doctor Training.

After his 18-year-old daughter Libby died within 24 hours of an emergency hospital admission in 1984, Zion learned that her chief doctors had been medical residents covering dozens of patients and receiving relatively little supervision. His anger set in motion a series of reforms, most notably a series of work hour limitations instituted by the Accreditation Council on Graduate Medical Education (ACGME), that have revolutionized modern medical education.

Residency programs have been in existence for many years – reportedly since the latter part of the 19th Century They were generally characterized as being “notoriously rigorous” with these young physicians-in-training putting in over 100 hours a week in patient care.

What followed in the wake of Libby Zion’s death and her father’s much publicized outrage led to a series of events culminating most recently in the June 23, 2010 announcement of the newest set of residency workload recommendations. In large part, however, it was the intervening history that led to these “newest recommendations.”

In May 1986 Manhattan District Attorney Robert Morgenthau agreed to let a grand jury consider murder charges. Although it declined to indict, the jury issued a report strongly criticizing “the supervision of interns and junior residents at a hospital in New York County.”

In response, New York State Health Commissioner David Axelrod established a blue-ribbon panel of experts headed by Bertrand M. Bell, an outspoken primary care physician at the Albert Einstein College of Medicine in the Bronx, to evaluate the training and supervision of doctors in the state. Bell had long criticized the lack of supervision of physicians-in-training.

In 1989, New York state adopted the Bell Commission’s recommendations that residents could not work more than 80 hours a week or more than 24 consecutive hours and that senior physicians needed to be physically present in the hospital at all times. Hospitals instituted so-called night floats, doctors who worked overnight to spell their colleagues, allowing them to adhere to the new rules.

Finally, in 2003, the Accreditation Council for Graduate Medical Education issued its first set of guidelines, limiting residents to 80 hours of work per week. As noted in last week’s article in The New York Times –

Five years later (in 2008), a national panel of experts criticized the accrediting organization for not limiting those work hours enough and for failing to address duty hour violations among different training programs. They recommended more stringent guidelines, among them an eye-glazing mandatory nap calculation that has residents sleeping for five hours between 10 p.m. and 6 a.m. when they’ve already worked longer than 15 hours but may still have to work an additional nine hours.

What then emerged was last week’s announcement of the newest set of residency workload recommendations.

While the focus throughout the history of these changes in residency training program guidelines has apparently been the modifications and restrictions on resident hours, what simply should not be lost in the discussion is the additional focus on supervision of residents by senior, more experienced physicians.

The following excerpt from the Wall Street Journal Online puts this second equally important aspect of the new guidelines in proper perspective:

The guidelines also include detailed expectations about direct supervision of younger residents by more experienced ones, in the hopes that a supervising doctor would catch any error before it affects a patient, according to Dr. Nasca.

In addition, the ACGME will step up its monitoring and enforcement of the requirements, conducting on-site visits of each institution annually beginning in July 2011. The site visits are likely to cost each institution about $12,000 to $15,000, according to Dr. Nasca.

Those programs that don’t comply with the rules could ultimately lose accreditation and be forced to disband.

The New York Times reporting on these new guidelines provides equal emphasis to the issue of supervision of these physicians-in-training.

“The pivotal dimension of teaching residents in the hospital is supervision,” Dr. Thomas J. Nasca, chief executive of the council and vice chairman of the task force, said during a telephone briefing Wednesday. Supervision “has not been standardized to a great extent. These standards set certain expectations.”

The guidelines are now open for a 45-day public-comment period and if approved by the board in September, will go into effect in July 2011.

The death of an 18 year old girl 26 years ago and the battle waged by her father have led to key changes in not only medical residency protocol – they have brought about a much more important end result – increased patient safety. It’s one thing for a physician-in-training to be exhausted; it’s quite another for patients to be injured and sometimes killed because of overly tired and inadequately supervised medical trainees.

One must wonder, however – would this system that existed for over 100 years have changed at all were it not for who it was who died and whose father it was that had the clout and power to bring about this change? At least Libby’s death appears to have not been in vain. The true test will be in the enforcement of compliance of these new “guidelines.”