JULY 2003
Volume 27 No. 7

New rules limiting residents' work hours will require increased efficiency, creativity

As of July 1, Stanford Hospital, along with all teaching hospitals nationwide, must comply with new rules aimed at ensuring patient safety by limiting the total number of weekly and consecutive hours residents work. While there is broad agreement that trainees must be rested enough to care for patients safely, most faculty and residents also agree that operating under the new rules - from the Accreditation Council for Graduate Medical Education - will require creativity, collaboration and increased efficiency.

At SHC, working groups of faculty and residents have spent months brainstorming solutions and developing new schedules to comply with the rules.

"I think we're as prepared as we could be," said Ross Downey, a chief resident in internal medicine, who helped develop the department's new schedule. "We've talked about this a lot and thought through all the possibilities."

The ACGME rules mean that residents must work fewer hours - a maximum of 80 hours weekly on average and no more than 30 hours consecutively - but must still fulfill all their patient-care responsibilities and learn everything a physician-trainee needs to know.

"Our challenge is to accomplish the same work in 10 to 15 percent less time. It's difficult because we're training our residents in some very technical skills that require a lot of practice," said Maurice Druzin, director of the OB/GYN residency program. Compounding the challenge, he noted, no additional funding is being provided to help hospitals comply with the rules.

To tackle the problem, the internal medicine department formed several working groups comprised of faculty and residents. The groups all agreed on the values they wanted to preserve: delivering high-quality patient care, working with a consistent team of colleagues, and optimizing resident education and well-being. The groups then developed several proposals to meet ACGME's requirements, ultimately choosing one as the most workable.

The new schedule introduces two night-float residents who arrive at 10 p.m., allowing the team resident to go home and sleep after completing sign-out rounds. The night floats supervise the remaining two interns until 7 a.m., when the resident returns for morning report. The two interns then go home at 1 p.m., while the team resident remains to complete the day's work. This schedule replaces the previous one in which the entire team of a resident and two interns stayed overnight when on call, often working 36 or more consecutive hours.

Peter Pompei, associate program director for the internal medicine residency program, explained that by having the on-call resident and interns overlap through the use of night floats, the resident can get some sleep and continuity of care is preserved by minimizing the frequency with which patients are handed off to physicians less familiar with their status.

The OB-GYN department's task was even more complicated because distinct schedules had to be developed for each of its four subspecialties. Druzin and associate program director Scott Oesterling each developed a proposed new schedule and then melded them into a single basic prototype under which three-person night teams and day teams were created, replacing the previous system of four-person teams that worked shifts of 24 to 36 hours.

Under the prototype schedule, the night team works five nights a week, starting at 5:30 or 7:30 p.m. (depending on the day) and working until either 7 or 9:30 a.m. The day team arrives for the last hour of the night team's shift so that the entire group can do morning rounds, after which the night team goes home. On the weekends, the day team splits up the night call, giving the night team the weekend off. Druzin presented this schedule to working groups of faculty and residents representing each of his department's subspecialties, and he then had each group adapt the schedule to that subspecialty's needs. Druzin shares the concern of many in academic medicine, that when residents must complete their patient-care duties within an allotted time, their educational time might be shortchanged. Under the new rules, then, "You have to eliminate redundancy, eliminate non-educational activities and maximize teaching time," he said. For example, while junior residents used to spend hours holding retractors for surgical cases, this activity may need to be curtailed because "that time would probably be better spent doing patient work on the floor," he said.

Pompei believes that the culture of housestaff education poses another hurdle, given the tradition of long work hours in medical training. Still, he and most other faculty agree that making sure residents are well-rested is important. "The same way we limit the hours pilots can work," he said, "it makes sense to avoid excessive fatigue for our residents so they can provide good patient care."

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The new rules from the Accreditation Council for Graduate Medical Education, effective July 1, require the following, all averaged over four weeks:

Residents are limited to a maximum of 80 duty hours per week, including in-house call.

Duty periods cannot last for more than 24 consecutive hours, although residents may remain on duty for up to six more hours to hand off patients, maintain continuity of care or participate in educational activities.

Residents cannot be scheduled for in-house call more than once every three nights.

Residents must be given one day out of seven free from all clinical and educational responsibilities.

Adequate time for rest and personal activities must be provided. At a minimum, this should consist of a 10-hour period provided between daily duty periods and after in-house call.