The ACGME has just announced it’s new proposals for duty hours and graduate medical education is stopped in its tracks just as we finish new intern orientations. Residency educators (including me) are now poring over the small print in the New England Journal tables or the sleek new ACGME website to understand how to create a schedule that complies with the new rules.
In addition to schedule making, residency educators are all staring at the new program requirements are all trying to “crack the code” in the new requirements, much like Keanu Reeves in the Matrix. Specifically, program directors want to know what will count as “qualified supervisor”, “fitness to duty”, “strategic napping”, or a “fatigue management strategy” so that programs don’t get the red flag the next time the ACGME site visitor comes knocking. So far, it sounds like residents can still supervise interns so attendings aren’t being asked to sleepover in their offices…just yet. This will likely generate some of the discussion for the 45-day public comment period on the proposed requirements.
One thing is clearly different - interns (first year residents) will only work 16 hours maximum while residents (after internship) can work longer – up to 28 hours (I should say 24+4). While it makes sense to protect the interns who are least experienced and most sensitive to fatigue, the current culture characterizes internship through the following promise: if you can “just get through intern year”, then it gets better. In fact, I think I stated this to many of our graduating medical students and incoming interns this month! After internship, residents currently look forward to more time for research and elective rotations, working on applications for future job/fellowship, studying for their boards, catching up on paying bills (or moonlighting to pay bills) and reacquainting with their family and friends. The promise is also more than just hours of life, its about the scut work associated with intern work improving later in residency. Residents can now go to their educational conferences or operate in the OR and leave their interns behind to doublecheck and triplecheck that the CT’s are done, labs are drawn, medications are adminstered, and patients actually get discharged. So what happens if this promise is broken? The rationale for preserving overnight call for residents is that they will get the clinical experience that they need at a time when they are ready and prepared. However, the escalation of work during training requires all of us to rephrase how we approach discussing internship and residency. Most importantly, what will the interns and residents think about breaking the promise?
The new rules also include more on handoffs, one of my favorite topics. While handoffs will undoubtedly be more frequent for interns working 16 hour shifts, programs are also asked to take steps to “minimize transitions of care”. They also require all residents to be competent in handoff communication and for programs to monitor handoffs so they are structured, effective and safe. As we’ve discussed before, it’s currently unclear what type of education works best, or how to monitor handoffs. Given our work in the area, our latest thought is that programs need a “handoff menu” so that different programs can “order” the types of education or evaluation tools (ranging from 5 minute lecture to simulation-based training) that will work best for their residents.
Given the need to scale up handoff education to all residents, it’s important to make learning about handoffs fun, interactive, and most of all QUICK. After all, getting time on the GME orientation calendar is not easy when you’re competing against needlesticks and computer training. So, with the help of a talented recent medical student graduate, we’ve developed a short video to highlight the pitfalls of handoffs and how not to do them for our new intern oriention that generated lots of positive feedback. (It’s now publicly posted on here as part of a social media contest this week for educational video of the month so please vote by sharing!).
And just when I thought we were onto something, two of our creative undergraduate students decided to go one step further with the following “Oh My God” Handoffs Cartoon based on the video which says it all in one page (read clockwise)! So, with all the fretting about how we will ensure the clinical education and professional development of the millenial generation with the new duty hour limits, we cannot forget to celebrate their incredible unique talents and nurture it for the betterment of medical education and patient care. Maybe they will figure out the best call schedule for the new rules too.
–Vineet Arora, MD
please email firstname.lastname@example.org for any information on our Handoff Menu or other tools
Disclosure: I have received funding from the ACGME to reviewthe literature to help inform the new standards and have also testified to the committee that created the new standards.