Starting this academic year (July 1, 2011), the Accreditation Council for Graduate Medical Education (ACGME) implemented substantial changes to the work-hour guidelines that have largely governed residency programs. The last major change was in 2003, when the ACGME introduced an 80-hour limit to the work week.
Given that residents play a large role in medical student teaching, how might this affect your education?
Under these new guidelines, PGY-1 (Post-Graduate Year 1) interns are not permitted to work for more than 16 consecutive hours. PGY-2 residents can work up to 24 consecutive hours. The ACGME chose not to recommend uninterrupted sleep time, instead advocating "strategic napping" after 16 hours of duty. As a result of these changes, for the first time, interns could potentially work fewer hours than more advanced residents.
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Prior to July 2003, work-hour limits were typically left to the discretion of the supervising physicians of each clinical service. After the ACGME recommended the 80-hour limits that year, it relied on residents self-reporting their hours—and any potential violations—to their superiors. Technically, programs are not bound to the ACGME's guidelines; however, programs that stray from these guidelines risk losing crucial Medicare funding that subsidizes resident salaries.
Even after many programs voluntarily adopted the 2003 duty hour limit, a number of residents have said that they felt pressure at some institutions to "underreport" work hours "for the good of the program," referring to potential ACGME scrutiny that could result from a pattern of reported violations of the new restrictions. In general, sanctions imposed by the ACGME could jeopardize program accreditation, which could potentially mean its graduates may no longer be eligible to take their specialty board exams.
Since the ACGME relies on residents to self-report violations to supervisors at their own institutions (in most cases not done anonymously), there is a perception at some programs that reporting duty hour violations could potentially subject residents to retaliation or being evaluated less favorably.
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By recommending these new work hour changes currently being implemented in the vast majority of residency programs, the ACGME hopes to:
• Reduce resident fatigue: New York pioneered the movement to curtail resident working hours after the 1984 death of an 18-year-old college student from what was later believed to have resulted from a preventable drug interaction. It was later publicized that only two residents were assigned to cover much of the busy hospital that night. An 80-hour limit to the work week was imposed on New York programs shortly thereafter.
After the ACGME implemented similar duty hour restrictions nationwide in 2003, studies have shown that a majority of residents reported working fewer hours overall, and that they felt their clinical education was not compromised. They also reported feeling that their quality of life had improved as a result.
• Increase educational opportunities: Examining the impact of duty hour limits, a Harvard University study of resident classes training both before and after the 2003 work-hour changes found that residents felt their patient case volume and sense of clinical preparedness were unchanged. The group training after the work-hour restrictions were implemented also felt they had more time to pursue research interests.
With residents likely working fewer hours, it could impact medical education in two important ways:
• Displacement of working time: On certain clinical services at some medical schools, it has been reported that after changes were implemented, medical students sometimes felt pressured to work longer hours than their own supervising residents (medical students are technically not subject to ACGME work-hour restrictions).
• Reduced teaching opportunities: Though hospitals differ, many residency programs have assigned trainees to the recommended shorter shifts, but left the number of patients they would need to cover largely unchanged. With residents potentially feeling rushed, this could result in fewer opportunities for medical student teaching.
The potential educational impact of recent changes in work-hour policies for residents, who traditionally play a large role in medical student teaching, is not yet certain. Because different medical schools adapt to these changes in different ways, it's important to be aware of upcoming changes when searching for the medical school that's the best fit for you.
Ibrahim Busnaina, M.D. is a graduate of the University of Pennsylvania School of Medicine and coauthor of "Examkrackers' How To Get Into Medical School." He has been consulting with prospective medical school applicants, with a special focus on minority and other nontraditional candidates, since 2006.