Patient Safety Advocates Give Plan to Reform Medical Residency a Failing Grade

WASHINGTON -  The coalition of public interest and patient safety groups that have
spearheaded the www.WakeUpDoctor.org
campaign issued a “report card” in response to today’s proposal by the
Accreditation Council on Graduate Medical Education (ACGME) to
restructure medical residency programs, published in The New England
Journal of Medicine. 

Since February, the Wake Up Doctor campaign has been instrumental in
raising awareness about the dangers posed by medical residents working
shifts as long as 30 hours, frequently with limited support or
supervision, leaving them exhausted and prone to mistakes. The
coalition, which includes Public Citizen, Mothers Against Medical Error
and other patient advocates, based their grades on the landmark 2008
report by the Institute of Medicine (IOM), Resident Duty Hours:
Enhancing Sleep, Supervision and Safety. The IOM report made a thorough
review of issues related to residency and listed 10 recommendations for
change, including an increase in supervision of junior residents and a
significant reduction in work hours.

Although ACGME, the group responsible for training physicians in the
United States, demonstrated some progress in reconciling its regulations
with the mounting body of scientific evidence linking acute and chronic
sleep deprivation with preventable medical errors, the coalition judged
that the proposal fails compared to the more comprehensive
recommendations of the IOM report.

*

Common Sense Limits on Resident Duty Hours
Grade:  F

The IOM report called for a reduction in resident duty hours from 30
consecutive-hour shifts to continuous shifts lasting no longer than 16
hours. The ACGME’s proposal implements that change only for medical
residents in their first year (interns). This change would therefore
only apply to 22 percent of total residents in hospitals throughout the
country. Most medical residents could continue to be scheduled for a
maximum of 24 consecutive hours, a duration rejected by the IOM in late
2008. Ample evidence has shown that marathon shifts in excess of 16
hours can have a detrimental effect on a physician’s abilities and
judgment.

Additionally, the IOM made a number of recommendations ranging from
the minimum time off between scheduled duty periods, the maximum number
of consecutive nights a resident may work night duty, adjustments to the
minimum amount of time off per week, and an immediate, urgent
requirement for hospitals to provide safe transportation home for
fatigued residents. Nearly all of these recommendations are left out of
the ACGME’s proposal.

 “Although it’s a positive step for the ACGME to make any
acknowledgement of the evidence linking resident fatigue and medical
error, its proposed solution misses the mark,” said Dr. Alex Blum, one
of the authors of the recent study, “US Public Opinion Regarding
Proposed Limits on Resident Physician Work Hours,” which was published
in BMC Medicine. “Physicians do not cease to be human beings when they
complete their first year of residency, nor does an additional year of
training make them impervious to the physiological effects of sleep
deprivation. Patients both deserve and expect to be treated by a
well-rested physician. The ACGME’s proposal on work hours won’t come
close to making that a reality.”

Adequate Direct, Onsite Supervision
Grade:  B

The IOM report called for first-year residents not to be “on duty
without having immediate access to a residency program-approved
supervisory physician in-house” (Summary, p.13).  The ACGME adopts this
measure, but only somewhat vaguely addresses the IOM report’s
recommendation for measurable standards of supervision for each level of
residency.

  “The ACGME has taken an important step in regard to supervision of
first-year residents and to setting specific standards for different
levels of supervision,” said Helen Haskell, founder and president of
Mothers Against Medical Error. “I think the acid test will be in the
details. We need to be sure that residents of all levels have sufficient
backup and reasonable limits on their workloads.”

Structured, Institutionalized Handover Processes
Grade:  C

 The IOM report called for medical residents to be trained to
communicate clearly and accurately when handing over patients after
residents’ shifts end, a process known as “handovers” or “signouts.” The
ACGME proposal includes this provision, as well as requiring a system
to quickly and accurately communicate to staff and patients the roles
and patient responsibilities of both residents and attending physicians
at any given time.

However, the IOM report also called for dedicated, protected and
overlapping time for patient care teams to conduct these transitions.
The ACGME proposal does not include this solution to reduce errors
related to handovers and improve team communication among providers.

“Without question, the environment in which handovers take place must
be closely monitored to prevent errors and potential harm for our
patients,” said Dr. Farbod Raiszadeh, president of the Committee of
Interns and Residents/SEIU Healthcare, the nation’s largest union for
housestaff. “However, I can say from experience that part of that
environment is how long the outgoing resident has been working in the
hospital and how fatigued they are at the time of transition. Handovers
are safer, more thorough and less prone to error when they occur in hour
16 than in hour 30 of a shift.”

Increased Oversight of Residency Programs
Grade:  F

 Although the ACGME plans to dramatically increase the number of site
visits, its oversight proposal falls far short of the IOM’s standard.
The IOM report called for rigorous oversight on the part of the ACGME,
including unannounced visits to teaching hospitals, strengthened
complaint procedures and confidential, protected reporting of hours by
residents and teaching hospitals - none of which is directly addressed
by the ACGME’s proposal. Additionally, the IOM report called for
independent monitoring by the Centers for Medicare and Medicaid Services
and the Joint Commission - a recommendation that is also absent from
the ACGME proposal, thus leaving the major control in the hands of the
non-governmental ACGME instead of increasing the role of the government
in oversight.

 “The improvements in the new ACGME guidelines are largely swamped by
the failure to cover the majority of medical residents with the
protection of not having to work more than 16 hours continuously,” said
Dr. Sidney Wolfe, director of Public Citizen’s Health Research Group.
“This is the second revision of ACGME requirements in the last seven
years and the organization still does not get it right.”
*

 The coalition will continue to educate the public concerning the
areas where the ACGME proposal fails to meet the standards set by the
2008 IOM report. 

To learn more about the issue of resident work hours, supervision and
safety, and to sign the campaign’s letter to the ACGME in support of
the IOM recommendations, visit www.WakeUpDoctor.org.