Guidelines will no longer curb the amount of hours first-year resident doctors work in one shift, as the Accreditation Council for Graduate Medical Education earlier this month that the new limit will be set at 24 and, if necessary to manage efficient shift changes, 28 hours in one shift.
The changes were made following a comprehensive 18-month review of guidelines, by a task force comprised of graduate medical education leaders, residents and one public member, according to the ACGME.
The team conducted an all-inclusive review process of specialized information including public remarks, evidence, research and opinions from medical educators as well as residents.
In addition to the rule revision, new teaching requirements in all residency programs will outline how to tend to patient safety, wellness and teamwork. All rules go into effect in July.
These additional requirements state that first-year residents must sufficiently sign out their work and patients to another resident at the end of every shift and for the lifetime of their career. Currently, they can work up to 16 hours before they must complete exchange.
“Effectively, this could decrease handoffs from two per 24 hours down to one per 24 hours for programs that make this change,” said Dr. Betty Chang, an associate professor in the Department of Internal Medicine at the Health Sciences Center.
During the four-hour gap between working 24 and 28 hours, these rookie doctors cannot take on any new patients or work of any kind, Chang said, and these first-year residents may leave as soon as their work is complete, which could only take one or two hours.
Matt Wharton, a first-year orthopedics resident, said working long hours is just part of the deal in becoming a doctor.
“Medicine is stressful and working long shifts can compound that stress,” Wharton said. “I think it’s important to self-assess how you’re doing and ask for help if you need it.”
Wharton said it can be difficult to balance everything socially, but being flexible with plans is essential.
“Luckily I have an incredibly supportive wife who’s been willing to go with the flow and adapt her schedule to mine accordingly,” Wharton said. “I think it’s important to have your significant other realize that plans may fall through due to unexpected demands at work.”
The handoff patient process can lead to issues with communication, according to Wharton, but longer shifts allow for a more streamlined flow.
“Many of our programs at UNM are not planning on making these changes, but staying with shorter shifts,” Chang said.
Chang does note that some of the surgical specialties are considering the increase in shift hours so that an intern may stay with the rest of the team, instead of leaving the group after 16 hours.
“None of these changes are mandatory. They are maximum hour requirements,” Chang said. “All programs schedule their residents with hours below these maximums, and most well below these maximums. The new requirements are to allow for flexibility in scheduling.”
There are also maximum limits set for duty hour requirements. Residents may not work over 80 hours averaged out over four weeks and must also average one day off per week, averaged out over another four week span.
“The reason for the averaging is that many residency programs and residents would prefer to have one weekend completely off, while working the other weekend,” Chang said. “This can only be done with averaging.”
During intense rotations, on average a resident can be scheduled for six days a week. On average, duty hours range between 38 and 80 hours per week, contingent on the particular program.
Opposition to the changes comes from the Public Citizen’s Health Research Group, the American Medical Student Association, and the Committee of Interns and Residents.
One randomized from the New England Journal of Medicine analyzed sleep-deprived interns working in intensive care units.
“Interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts,” the study stated. “Eliminating extended work shifts and reducing the number of hours interns work per week can reduce serious medical errors in the intensive care unit.”
Although there are no scheduled breaks for physicians in residency and in practice, Chang said they unite as a team to take breaks when they can. During slow times, they often eat together.
“Under the new requirements, programs need to teach residents self awareness, to let others know when they are fatigued and to recognize fatigue in others,” Chang said. “This way, as a team, they can relieve one another for rest breaks and understand when others need a break because of fatigue. The current system emphasizes hours and not teamwork.”
The 16-hour cap, according to Chang, is not flexible and does not mirror realistic events for residents who eventually go out in practice on their own.
“If they are at the operating table, they cannot finish the case. If they are attending to a sick patient, they have to leave. The new requirements allow for that first year resident to assess what is best in each situation,” Chang said. “Sometimes it is best for the resident to stay with the patent; sometimes, it is best for the resident to sign off to someone else and get rest. This self awareness will make for better doctors in the future.”
Sarah Trujillo is a news reporter at the Daily Lobo. She can be reached at firstname.lastname@example.org or on Twitter @sarahtweets_abq.