- Email: [email protected]
Understanding Accreditation Council for Graduate Medical Education (ACGME) Guidelines: Resident and Program Director Interpretation of Work-Hour Restrictions
2009 APDS SPRING MEETING
Understanding Accreditation Council for Graduate Medical Education (ACGME) Guidelines: Resident and Program Director Interpretation of Work-Hour Restrictions Martin E. Schlueter, MD, Peter H. Phan, MD, Christopher S. E. Martin, MD, Dan Breece, DO, and Dennis A. Boysen, MD Synergy Medical Education Alliance, a residency program in Saginaw, MI PURPOSE: All residency programs must comply with the Ac-
creditation Council for Graduate Medical Education (ACGME) work-hour guidelines, but compliance requires accurate interpretation of the rules. We previously surveyed the residents and program directors of general surgery residency programs and found significant discordance between what program directors and residents considered violations. Our current study expands our research to include family medicine and emergency medicine residents and program directors. This study aims to identify discrepancies of work-hour guideline interpretation within and between the specialties. METHODS: We created 10 scenarios related to work-hour
issues. The ACGME reviewed them and judged whether a violation occurred in each scenario. From these scenarios, an Internet-based survey was generated and distributed electronically to every family medicine and emergency medicine residency in the United States. (Surgery programs were previously surveyed from March 1 through May 21, 2007 with the same scenarios.) Responses were collected anonymously via our Internet-based survey database from March 1 through May 17, 2008. All respondents were asked to identify themselves as either a program director or a resident. After reading each scenario, participants were asked to answer either “yes,” “no,” or “maybe/not sure.” The option of “maybe/not sure” was in place to discourage guessing; those responses were not included in our analysis. After the data were collected, we calculated the percent of respondents that answered “yes” or “no” for each of the 10 scenarios related to work-hour issues. The results from within specialties (program directors vs residents) and between specialties (general surgery, family medicine, emergency medicine) were compared.
Correspondence: Inquiries to Peter Phan, MD, Department of Surgery, Synergy Medical Education Alliance, 1000 Houghton Avenue, Saginaw, MI 48602; fax: (989) 583-6989; e-mail: [email protected]
374
RESULTS: There were a total of 883 respondents (334 general surgery, 374 family medicine, and 175 emergency medicine). Respondents identified themselves as program directors (97), assistant program directors (21), or residents (765). Statistically significant differences were identified in the responses of program directors and residents within and between specialties. CONCLUSIONS: Based on the scenarios we presented, there
was a difference in interpretation between residents and program directors. There was even disagreement among program directors of different specialties on the interpretation of some of the scenarios. This finding reveals an ambiguity in the workhour restrictions. We conclude that the ACGME-mandated work-hour guidelines are confusing and not universally understood. This problem is compounded by the cross-training with “off-service” residents from other specialties such as family medicine and emergency medicine. Hence, enforcement of the work-hour restrictions may be problematic, despite the best intentions and sincere effort of directors and residents to interpret the rules. (J Surg 66:374-378. © 2009 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: duty hours, residency, ACGME COMPETENCY: Patient Care, Interpersonal and Communi-
cation Skills, Professionalism
INTRODUCTION On July 1, 2003, new program and institutional requirements went into effect to regulate the duty hours of residents. The standards can be found on the ACGME website, http://www. acgme.org. They include the following: duty hours limited to 80 hours per week averaged over 4 weeks; 1 day in 7 consecutive days free from all educational and clinical responsibilities; continuous duty capped at 24 hours with up to 6 additional hours
Journal of Surgical Education • © 2009 Association of Program Directors in Surgery Published by Elsevier Inc. All rights reserved.
1931-7204/09/$30.00 doi:10.1016/j.jsurg.2009.05.002
for transfer of care; and in-house call to be no more frequent than every third night. Home call is permitted, but if the resident is called in, the time spent in the hospital counts toward the 80-hour limit. Numerous studies have examined the impact of these guidelines on operative volume, resident education, and patient care. However, a paucity of data is available on how accurately the guidelines are interpreted and whether program directors’ and residents’ interpretations agree. We previously surveyed the program directors and residents of general surgery programs and identified statistically significant differences in their understanding of the Accreditation Council for Graduate Medical Education (ACGME) work-hour restrictions. Our current study expands this research to family medicine and emergency medicine programs to assess their responses and compare how program directors and residents of different specialties interpret the guidelines.
Sunday to begin rounds. Also, during this 24-hour period, the resident has no clinical duties or obligations whatsoever. Has this resident had a day off? Yes 3. A resident attends a mandatory journal club in the evening at 6 PM. The journal club is over at 8 PM. The following morning, the resident begins rounding at 5.30 AM. Has a violation occurred? No 4. October has 5 weekends. The resident on service takes every Sunday off and counts this toward 4 RRC days off. On the fifth weekend, the resident would like to take Saturday as his day off. He is told, “No, you’ve already had your 4 days off.” Has a violation occurred? Authors’ answer: Yes. ACGME response: It is not possible to tell from the scenario. There needs to be a day off for every 7 days, with a partial day for remaining days in a month potentially split with the next month (minimum compliance) or more than 4 days off in a given month. Ideally, there should be 5 days off in that month; however, the ACGME does not speak to whether the resident should/could have Saturday versus another day off.
METHODS We created 10 scenarios related to work-hour issues. From these scenarios, an Internet-based survey was generated and distributed electronically to every emergency medicine and family medicine residency in the United States. Responses were collected anonymously via our Internet-based survey database. All respondents were asked to identify themselves as either a program director or a resident. Data were collected from March 1 through May 17, 2008. (The same survey was sent to general surgery programs from March 1 through May 21, 2007.) After reading each scenario, participants were asked to answer either “yes,” “no,” or “maybe/ not sure.” An answer of “maybe/not sure” was not excluded from the analysis; this was done to eliminate guessing the correct answer. We calculated the percent of respondents that answered “yes” or “no” for each of the 10 scenarios and ran a 2 analysis on the data to determine whether a difference existed in the pattern of answers between program directors and residents within each specialty. Furthermore, we looked for differences in the responses of program directors from different specialties. Finally, we compared the responses of residents from different specialties. Below are the 10 scenarios. The correct answer is given after each scenario. In 2 scenarios (numbers 4 and 5), the ACGME felt that a correct answer could not be deduced from the scenario; in those cases, the authors’ answer is given followed by the ACGME’s response 1. A resident is 26 hours into a shift (postcall) and gets paged by the emergency department for a consult on a patient that underwent a procedure by the resident’s attending 2 months prior. The resident does the consult. Is this a violation of the “no new patients post call” policy? No 2. A resident completes rounds Saturday morning at 9 AM. The resident does not return to the hospital until 9 AM on
TABLE 1. Family Medicine Responses Program Directors
Residents
Yes No*
31 4
252 61
Yes* No
30 6
234 86
Yes No*
27 7
155 149
Yes* No
12 15
82 164
Yes No*
14 18
162 91
Yes No*
6 27
101 180
Yes No*
16 17
128 184
Yes No*
13 14
165 129
Yes* No 10 Yes No*
13 16
155 117
10 24
96 188
Question # 1
P Value 0.246
2
0.185
3
0.002
4
0.249
5
0.026
6
0.042
7
0.409
8
0.425
9
0.210 0.608
Bold P value ⫽ statistical significance. *Correct answer.
Journal of Surgical Education • Volume 66/Number 6 • November/December 2009
375
TABLE 2. Emergency Medicine Responses Program Directors
Residents
Yes No*
39 2
98 18
Yes* No
38 5
90 34
Yes No*
22 17
48 63
Yes* No
8 25
24 89
Yes No*
11 21
50 35
Question # 1
P Value 0.079
2
0.035
3
0.156
4
0.714
5
0.018
6
0.367 Yes No*
22 18
48 55
Yes No*
7 31
16 89
Yes No*
13 23
37 80
Yes* No 10 Yes No*
15 20
45 63
7
0.647
8
0.616
9
0.901 0.538 8 32
29 88
RESULTS A total of 883 individuals responded to the survey. Of those, 374 identified themselves as family medicine (34 program directors and 340 residents); 175 as emergency medicine (42 program directors and 133 residents); and 334 as general surgery (42 program directors and 292 residents). From the family
TABLE 3. General Surgery Responses Program Directors
Residents
Yes No*
21 18
187 68
Yes* No
31 10
224 55
Yes No*
28 10
115 144
Yes* No
16 13
90 154
Yes No*
15 22
101 129
Yes No*
12 29
87 156
Yes No*
10 24
107 145
Yes No*
15 19
114 142
Yes* No 10 Yes No*
6 31
82 156
8 30
58 193
Question # 1
Bold P value ⫽ statistical significance. *Correct answer.
P Value 0.0213
2
5. The resident receives a call very late at night from a nurse regarding a postoperative patient that resident was involved with earlier that afternoon. The resident informs the nursing staff that he is not on call. The nurse responds, “I know you’re not on call. We were told to call you by the attending surgeon.” Has a violation occurred? Authors’ answer: No (even though the strictest interpretation of the ACGME guideline for 10 hours free of clinical duties between shifts might deem this a violation). ACGME response: It is not possible to tell from the scenario. If the resident is not on call, another resident or staff should be available to care for the patient, and the resident should not be forced to see this patient. The resident may, however, want to care for this patient to be involved in his/her postoperative care. 6. A resident is on call in-house from 8 AM Saturday until 8 AM Monday. After 24 hours of call (ie, 8 AM Sunday), the resident has a 10-hour time-off period. After that 10-hour time off, the resident returns to finish the remaining 14 hours of call. Has a violation occurred? No 7. Can a postcall resident see new patients in the clinic? No 376
8. A resident reviews the call schedule and notices that he has been put on call every other night for the entire week. When asked, the chief resident responds, “I did it that way so you could have more time off the following week.” Has a violation occurred? No 9. A resident works 10 hours on their research project during their weekend off. This research is a mandatory requirement for the program. Should the resident document the time spent toward their 80 hours? Yes 10. If a resident takes a week of vacation, should the resident’s work hours be averaged over a 4-week period? No
0.6261
3
0.0014
4
0.0875
5
0.8372
6
0.5254
7
0.2052
8
0.9636
9
0.0431 0.9411
Bold P value ⫽ statistical significance. *Correct answer.
Journal of Surgical Education • Volume 66/Number 6 • November/December 2009
medicine responses, we identified 3 scenarios with statistically significant differences in the responses of program directors and residents (Table 1). Two scenarios elicited significantly different responses from the emergency medicine respondents (Table 2), and 3 scenarios showed differences among the general surgeons (Table 3). We compared the responses of program directors of the 3 specialties and identified statistically significant differences in their responses for 5 scenarios (Table 4). Residents of the 3 specialties differed in their responses for 7 scenarios (Table 5).
TABLE 5. Resident Responses by Specialty
DISCUSSION
4
The first scenario illustrated a common situation in which a resident is asked to observe an established patient in the emergency department even though he or she has worked more than 24 hours of continuous duty. Most respondents incorrectly called this a violation. Approximately half of the general surgery program directors correctly answered this question, differing significantly from their colleagues in family and emergency medicine. This suggests that residents may incorrectly report a violation during a surgery rotation when asked to perform this duty.
1
P Value <0.001
Yes No*
31 4
39 2
21 18
Yes* No
30 6
38 5
31 10
2
0.302
3
0.081 Yes No*
27 7
22 17
28 10
Yes* No
12 15
8 25
16 13
Yes No*
14 18
11 21
15 22
Yes No*
6 27
22 18
12 29
Yes No*
16 17
7 31
10 24
Yes No*
13 14
13 23
15 19
Yes* No 10 Yes No*
13 16
15 20
6 31
10 24
8 32
8 30
4
0.041
5
0.737
6
0.003
7
0.023
8
0.61
9
0.018 0.587
Bold P value ⫽ statistical significance. *Correct answer.
1
P Value 0.027
Yes No*
252 61
98 18
187 68
Yes* No
234 86
90 34
224 55
Yes No*
155 149
48 63
115 144
Yes* No
82 164
24 89
90 154
Yes No*
162 91
50 35
101 129
Yes No*
101 180
48 55
87 156
Yes No*
128 184
16 89
107 145
Yes No*
165 129
37 80
114 142
Yes* No 10 Yes No*
155 117
45 63
82 156
96 188
29 88
58 193
2
0.082
3
0.213 0.013
5
<0.001
6
0.121
7
<0.001
8
<0.001
9
TABLE 4. Program Director Responses by Specialty Question Family Emergency General # Medicine Medicine Surgery
Question Family Emergency General # Medicine Medicine Surgery
<0.001 0.016
Bold P value ⫽ statistical significance. *Correct answer.
The third scenario pertained to “adequate rest.” When designing this survey, the authors believed a violation occurred because the resident had less than 10 hours before resuming clinical duties. However, Dr Ingrid Philibert, who is Sen. VicePresident of Field Activities of the ACGME, concluded that it was not a violation and stated, “Adequate rest should be provided. This generally should consist of 10 hours. This should allow occasional shorter rest with educational justifications. The journal club qualifies for that. It is assumed that this is an occasional, certainly no more than weekly, occurrence.” Most family medicine program directors erred on the side of calling this a violation. In contrast, the residents were split on whether a violation occurred or not. From this, it seems that the requirements for rest are vague or misunderstood. The fourth scenario identified statistically significant differences between the specialties with regard to meeting the ACGME requirement for 1 day off in 7 consecutive days. More than half of the surgery program directors answered correctly, whereas most (25 out of 33) emergency medicine program directors answered incorrectly. A similar trend was observed among the residents; only 21% of emergency medicine residents answered correctly versus 33% and 36% of family medicine and surgery residents.
Journal of Surgical Education • Volume 66/Number 6 • November/December 2009
377
ACGME rules require that rest periods between shifts be free of clinical duties. Scenario 5 dramatically highlights a difference in how surgical residents reacted differently than emergency medicine and family medicine residents. Many surgery residents (129 out of 230) viewed no problem with caring for a postoperative patient even if that resident was not on call. Conversely, most family medicine and emergency medicine residents deemed this a violation. The ACGME replied that the correct answer could not be deduced from the scenario. (It is the authors’ position that this should not be a violation.) In the sixth scenario, most family medicine and surgery program directors answered correctly (ie, no violation occurred). In contrast, 22 of 40 emergency medicine program directors incorrectly deemed this a violation. To quote from the ACGME document Frequently-asked Questions about the ACGME Common Duty Hour Standards (updated April 2007), “in-house call on two consecutive nights (e.g., Friday and Saturday) must include adequate rest (generally 10 hours) between the two duty shifts.”
378
In summary, our study identified significant differences in how program directors and residents of different specialties interpret the ACGME duty-hour standards. This makes compliance difficult. Furthermore, our research suggests that additional confusion arises when residents are crosstrained in other specialties, as the program directors of those specialties may interpret the rules differently. A violation of the duty hours can jeopardize a program’s accreditation, and the ACGME attempted to clarify the rules with its April 2007 update to Frequently-asked Questions. Our study suggests a need for additional clarification, with specialty-specific examples.
ACKNOWLEDGMENT The authors wish to thank Dr Ingrid Philibert, who is the Sr. Vice-President, Field Activities of the ACGME, for providing responses to our questionnaire. We also thank Mr John Clements for his assistance with the statistical analysis.
Journal of Surgical Education • Volume 66/Number 6 • November/December 2009
Understanding Accreditation Council for Graduate Medical Education (ACGME) Guidelines: Resident and Program Director Interpretation of Work-Hour Restrictions Martin E. Schlueter, MD, Peter H. Phan, MD, Christopher S. E. Martin, MD, Dan Breece, DO, and Dennis A. Boysen, MD Synergy Medical Education Alliance, a residency program in Saginaw, MI PURPOSE: All residency programs must comply with the Ac-
creditation Council for Graduate Medical Education (ACGME) work-hour guidelines, but compliance requires accurate interpretation of the rules. We previously surveyed the residents and program directors of general surgery residency programs and found significant discordance between what program directors and residents considered violations. Our current study expands our research to include family medicine and emergency medicine residents and program directors. This study aims to identify discrepancies of work-hour guideline interpretation within and between the specialties. METHODS: We created 10 scenarios related to work-hour
issues. The ACGME reviewed them and judged whether a violation occurred in each scenario. From these scenarios, an Internet-based survey was generated and distributed electronically to every family medicine and emergency medicine residency in the United States. (Surgery programs were previously surveyed from March 1 through May 21, 2007 with the same scenarios.) Responses were collected anonymously via our Internet-based survey database from March 1 through May 17, 2008. All respondents were asked to identify themselves as either a program director or a resident. After reading each scenario, participants were asked to answer either “yes,” “no,” or “maybe/not sure.” The option of “maybe/not sure” was in place to discourage guessing; those responses were not included in our analysis. After the data were collected, we calculated the percent of respondents that answered “yes” or “no” for each of the 10 scenarios related to work-hour issues. The results from within specialties (program directors vs residents) and between specialties (general surgery, family medicine, emergency medicine) were compared.
Correspondence: Inquiries to Peter Phan, MD, Department of Surgery, Synergy Medical Education Alliance, 1000 Houghton Avenue, Saginaw, MI 48602; fax: (989) 583-6989; e-mail: [email protected]
374
RESULTS: There were a total of 883 respondents (334 general surgery, 374 family medicine, and 175 emergency medicine). Respondents identified themselves as program directors (97), assistant program directors (21), or residents (765). Statistically significant differences were identified in the responses of program directors and residents within and between specialties. CONCLUSIONS: Based on the scenarios we presented, there
was a difference in interpretation between residents and program directors. There was even disagreement among program directors of different specialties on the interpretation of some of the scenarios. This finding reveals an ambiguity in the workhour restrictions. We conclude that the ACGME-mandated work-hour guidelines are confusing and not universally understood. This problem is compounded by the cross-training with “off-service” residents from other specialties such as family medicine and emergency medicine. Hence, enforcement of the work-hour restrictions may be problematic, despite the best intentions and sincere effort of directors and residents to interpret the rules. (J Surg 66:374-378. © 2009 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: duty hours, residency, ACGME COMPETENCY: Patient Care, Interpersonal and Communi-
cation Skills, Professionalism
INTRODUCTION On July 1, 2003, new program and institutional requirements went into effect to regulate the duty hours of residents. The standards can be found on the ACGME website, http://www. acgme.org. They include the following: duty hours limited to 80 hours per week averaged over 4 weeks; 1 day in 7 consecutive days free from all educational and clinical responsibilities; continuous duty capped at 24 hours with up to 6 additional hours
Journal of Surgical Education • © 2009 Association of Program Directors in Surgery Published by Elsevier Inc. All rights reserved.
1931-7204/09/$30.00 doi:10.1016/j.jsurg.2009.05.002
for transfer of care; and in-house call to be no more frequent than every third night. Home call is permitted, but if the resident is called in, the time spent in the hospital counts toward the 80-hour limit. Numerous studies have examined the impact of these guidelines on operative volume, resident education, and patient care. However, a paucity of data is available on how accurately the guidelines are interpreted and whether program directors’ and residents’ interpretations agree. We previously surveyed the program directors and residents of general surgery programs and identified statistically significant differences in their understanding of the Accreditation Council for Graduate Medical Education (ACGME) work-hour restrictions. Our current study expands this research to family medicine and emergency medicine programs to assess their responses and compare how program directors and residents of different specialties interpret the guidelines.
Sunday to begin rounds. Also, during this 24-hour period, the resident has no clinical duties or obligations whatsoever. Has this resident had a day off? Yes 3. A resident attends a mandatory journal club in the evening at 6 PM. The journal club is over at 8 PM. The following morning, the resident begins rounding at 5.30 AM. Has a violation occurred? No 4. October has 5 weekends. The resident on service takes every Sunday off and counts this toward 4 RRC days off. On the fifth weekend, the resident would like to take Saturday as his day off. He is told, “No, you’ve already had your 4 days off.” Has a violation occurred? Authors’ answer: Yes. ACGME response: It is not possible to tell from the scenario. There needs to be a day off for every 7 days, with a partial day for remaining days in a month potentially split with the next month (minimum compliance) or more than 4 days off in a given month. Ideally, there should be 5 days off in that month; however, the ACGME does not speak to whether the resident should/could have Saturday versus another day off.
METHODS We created 10 scenarios related to work-hour issues. From these scenarios, an Internet-based survey was generated and distributed electronically to every emergency medicine and family medicine residency in the United States. Responses were collected anonymously via our Internet-based survey database. All respondents were asked to identify themselves as either a program director or a resident. Data were collected from March 1 through May 17, 2008. (The same survey was sent to general surgery programs from March 1 through May 21, 2007.) After reading each scenario, participants were asked to answer either “yes,” “no,” or “maybe/ not sure.” An answer of “maybe/not sure” was not excluded from the analysis; this was done to eliminate guessing the correct answer. We calculated the percent of respondents that answered “yes” or “no” for each of the 10 scenarios and ran a 2 analysis on the data to determine whether a difference existed in the pattern of answers between program directors and residents within each specialty. Furthermore, we looked for differences in the responses of program directors from different specialties. Finally, we compared the responses of residents from different specialties. Below are the 10 scenarios. The correct answer is given after each scenario. In 2 scenarios (numbers 4 and 5), the ACGME felt that a correct answer could not be deduced from the scenario; in those cases, the authors’ answer is given followed by the ACGME’s response 1. A resident is 26 hours into a shift (postcall) and gets paged by the emergency department for a consult on a patient that underwent a procedure by the resident’s attending 2 months prior. The resident does the consult. Is this a violation of the “no new patients post call” policy? No 2. A resident completes rounds Saturday morning at 9 AM. The resident does not return to the hospital until 9 AM on
TABLE 1. Family Medicine Responses Program Directors
Residents
Yes No*
31 4
252 61
Yes* No
30 6
234 86
Yes No*
27 7
155 149
Yes* No
12 15
82 164
Yes No*
14 18
162 91
Yes No*
6 27
101 180
Yes No*
16 17
128 184
Yes No*
13 14
165 129
Yes* No 10 Yes No*
13 16
155 117
10 24
96 188
Question # 1
P Value 0.246
2
0.185
3
0.002
4
0.249
5
0.026
6
0.042
7
0.409
8
0.425
9
0.210 0.608
Bold P value ⫽ statistical significance. *Correct answer.
Journal of Surgical Education • Volume 66/Number 6 • November/December 2009
375
TABLE 2. Emergency Medicine Responses Program Directors
Residents
Yes No*
39 2
98 18
Yes* No
38 5
90 34
Yes No*
22 17
48 63
Yes* No
8 25
24 89
Yes No*
11 21
50 35
Question # 1
P Value 0.079
2
0.035
3
0.156
4
0.714
5
0.018
6
0.367 Yes No*
22 18
48 55
Yes No*
7 31
16 89
Yes No*
13 23
37 80
Yes* No 10 Yes No*
15 20
45 63
7
0.647
8
0.616
9
0.901 0.538 8 32
29 88
RESULTS A total of 883 individuals responded to the survey. Of those, 374 identified themselves as family medicine (34 program directors and 340 residents); 175 as emergency medicine (42 program directors and 133 residents); and 334 as general surgery (42 program directors and 292 residents). From the family
TABLE 3. General Surgery Responses Program Directors
Residents
Yes No*
21 18
187 68
Yes* No
31 10
224 55
Yes No*
28 10
115 144
Yes* No
16 13
90 154
Yes No*
15 22
101 129
Yes No*
12 29
87 156
Yes No*
10 24
107 145
Yes No*
15 19
114 142
Yes* No 10 Yes No*
6 31
82 156
8 30
58 193
Question # 1
Bold P value ⫽ statistical significance. *Correct answer.
P Value 0.0213
2
5. The resident receives a call very late at night from a nurse regarding a postoperative patient that resident was involved with earlier that afternoon. The resident informs the nursing staff that he is not on call. The nurse responds, “I know you’re not on call. We were told to call you by the attending surgeon.” Has a violation occurred? Authors’ answer: No (even though the strictest interpretation of the ACGME guideline for 10 hours free of clinical duties between shifts might deem this a violation). ACGME response: It is not possible to tell from the scenario. If the resident is not on call, another resident or staff should be available to care for the patient, and the resident should not be forced to see this patient. The resident may, however, want to care for this patient to be involved in his/her postoperative care. 6. A resident is on call in-house from 8 AM Saturday until 8 AM Monday. After 24 hours of call (ie, 8 AM Sunday), the resident has a 10-hour time-off period. After that 10-hour time off, the resident returns to finish the remaining 14 hours of call. Has a violation occurred? No 7. Can a postcall resident see new patients in the clinic? No 376
8. A resident reviews the call schedule and notices that he has been put on call every other night for the entire week. When asked, the chief resident responds, “I did it that way so you could have more time off the following week.” Has a violation occurred? No 9. A resident works 10 hours on their research project during their weekend off. This research is a mandatory requirement for the program. Should the resident document the time spent toward their 80 hours? Yes 10. If a resident takes a week of vacation, should the resident’s work hours be averaged over a 4-week period? No
0.6261
3
0.0014
4
0.0875
5
0.8372
6
0.5254
7
0.2052
8
0.9636
9
0.0431 0.9411
Bold P value ⫽ statistical significance. *Correct answer.
Journal of Surgical Education • Volume 66/Number 6 • November/December 2009
medicine responses, we identified 3 scenarios with statistically significant differences in the responses of program directors and residents (Table 1). Two scenarios elicited significantly different responses from the emergency medicine respondents (Table 2), and 3 scenarios showed differences among the general surgeons (Table 3). We compared the responses of program directors of the 3 specialties and identified statistically significant differences in their responses for 5 scenarios (Table 4). Residents of the 3 specialties differed in their responses for 7 scenarios (Table 5).
TABLE 5. Resident Responses by Specialty
DISCUSSION
4
The first scenario illustrated a common situation in which a resident is asked to observe an established patient in the emergency department even though he or she has worked more than 24 hours of continuous duty. Most respondents incorrectly called this a violation. Approximately half of the general surgery program directors correctly answered this question, differing significantly from their colleagues in family and emergency medicine. This suggests that residents may incorrectly report a violation during a surgery rotation when asked to perform this duty.
1
P Value <0.001
Yes No*
31 4
39 2
21 18
Yes* No
30 6
38 5
31 10
2
0.302
3
0.081 Yes No*
27 7
22 17
28 10
Yes* No
12 15
8 25
16 13
Yes No*
14 18
11 21
15 22
Yes No*
6 27
22 18
12 29
Yes No*
16 17
7 31
10 24
Yes No*
13 14
13 23
15 19
Yes* No 10 Yes No*
13 16
15 20
6 31
10 24
8 32
8 30
4
0.041
5
0.737
6
0.003
7
0.023
8
0.61
9
0.018 0.587
Bold P value ⫽ statistical significance. *Correct answer.
1
P Value 0.027
Yes No*
252 61
98 18
187 68
Yes* No
234 86
90 34
224 55
Yes No*
155 149
48 63
115 144
Yes* No
82 164
24 89
90 154
Yes No*
162 91
50 35
101 129
Yes No*
101 180
48 55
87 156
Yes No*
128 184
16 89
107 145
Yes No*
165 129
37 80
114 142
Yes* No 10 Yes No*
155 117
45 63
82 156
96 188
29 88
58 193
2
0.082
3
0.213 0.013
5
<0.001
6
0.121
7
<0.001
8
<0.001
9
TABLE 4. Program Director Responses by Specialty Question Family Emergency General # Medicine Medicine Surgery
Question Family Emergency General # Medicine Medicine Surgery
<0.001 0.016
Bold P value ⫽ statistical significance. *Correct answer.
The third scenario pertained to “adequate rest.” When designing this survey, the authors believed a violation occurred because the resident had less than 10 hours before resuming clinical duties. However, Dr Ingrid Philibert, who is Sen. VicePresident of Field Activities of the ACGME, concluded that it was not a violation and stated, “Adequate rest should be provided. This generally should consist of 10 hours. This should allow occasional shorter rest with educational justifications. The journal club qualifies for that. It is assumed that this is an occasional, certainly no more than weekly, occurrence.” Most family medicine program directors erred on the side of calling this a violation. In contrast, the residents were split on whether a violation occurred or not. From this, it seems that the requirements for rest are vague or misunderstood. The fourth scenario identified statistically significant differences between the specialties with regard to meeting the ACGME requirement for 1 day off in 7 consecutive days. More than half of the surgery program directors answered correctly, whereas most (25 out of 33) emergency medicine program directors answered incorrectly. A similar trend was observed among the residents; only 21% of emergency medicine residents answered correctly versus 33% and 36% of family medicine and surgery residents.
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ACGME rules require that rest periods between shifts be free of clinical duties. Scenario 5 dramatically highlights a difference in how surgical residents reacted differently than emergency medicine and family medicine residents. Many surgery residents (129 out of 230) viewed no problem with caring for a postoperative patient even if that resident was not on call. Conversely, most family medicine and emergency medicine residents deemed this a violation. The ACGME replied that the correct answer could not be deduced from the scenario. (It is the authors’ position that this should not be a violation.) In the sixth scenario, most family medicine and surgery program directors answered correctly (ie, no violation occurred). In contrast, 22 of 40 emergency medicine program directors incorrectly deemed this a violation. To quote from the ACGME document Frequently-asked Questions about the ACGME Common Duty Hour Standards (updated April 2007), “in-house call on two consecutive nights (e.g., Friday and Saturday) must include adequate rest (generally 10 hours) between the two duty shifts.”
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In summary, our study identified significant differences in how program directors and residents of different specialties interpret the ACGME duty-hour standards. This makes compliance difficult. Furthermore, our research suggests that additional confusion arises when residents are crosstrained in other specialties, as the program directors of those specialties may interpret the rules differently. A violation of the duty hours can jeopardize a program’s accreditation, and the ACGME attempted to clarify the rules with its April 2007 update to Frequently-asked Questions. Our study suggests a need for additional clarification, with specialty-specific examples.
ACKNOWLEDGMENT The authors wish to thank Dr Ingrid Philibert, who is the Sr. Vice-President, Field Activities of the ACGME, for providing responses to our questionnaire. We also thank Mr John Clements for his assistance with the statistical analysis.
Journal of Surgical Education • Volume 66/Number 6 • November/December 2009