ACGME Congress on Resident Learning and Working Environment: ACEP Testimony and Position Paper

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(reprinted with permission)

Stephen Wolf, MD, FACEP

Chair, ACEP Task Force on Resident Duty Hours

I would like to thank the ACGME for inviting the American College of Emergency Physicians to testify before today’s Congress. My name is Stephen Wolf, I am here today as a past residency program director, chair of the task force that authored ACEP written response, and representative of ACEP Board. ACEP represents over 32,000 emergency physicians nationally with member representatives at nearly every allopathic and osteopathic accredited EM residency training programs. ACEP has always placed the highest priority on residency training in emergency medicine; and, we have long fostered close and collaborative relationships with our sister organizations, the Council of Residency Directors in Emergency Medicine (CORD), the Society for Academic Emergency Medicine (SAEM), and the Emergency Medicine Residents Association (EMRA) around graduate medical education.

In response to the ACGME’s initial request for our position paper and in preparation for this testimony, ACEP convened a working group of 12 experts with extensive experience in graduate medical education. We reviewed the relevant literature and conducted a survey of 161 national stakeholders in emergency medicine resident education. We explored the impact of current DH standards on patient care and safety, programmatic resources, resident case load and competency, and educational experience. Informed by this information, ACEP puts forth the following testimony centered on three points.

First, ACEP and emergency medicine support individualized and evidence-based duty hour standards that advance patient safety, foster resident wellness, and maximize the learning environment.

When implemented in 2003 and 2011, the current ACGME duty hour standards had little impact on emergency medicine because, as a specialty, we were already adhering to self-determined standards appropriate to our practice environment. These standards ensured on-site supervision, shift length limitations, and limited consecutive days worked. For EM, our standards prioritize patient safety while fostering resident wellness in a quality learning environment. The greatest advantage to our self-imposed DH standards was that they were individualized and customized to our own practice setting. And while current EM DH standards largely remain as such, for other specialties this is not the case. ACEP strongly encourages the ACGME to explore individualized DH standards for each specialty to maximize goals of patient safety, wellness AND learning.

Next, ACEP has concerns that current ACGME DH standards negatively impact both patient safety and the quality of resident training.

Current standards aim to promote patient safety by minimizing medical errors made by fatigued resident providers and improving resident wellbeing. However, recent systematic reviews and studies suggest that these efforts may be misguided and in fact may negatively impact on resident education.  These findings are consistent with the results of our submitted survey. One explanation for this is that most non-EM specialties have adapted to current restrictions by implementing shift-based schedules. This change has dramatically increased the number of patient hand-offs both among consultants and in the admission process. While, literature clearly links patient handoffs to increase medical errors, our survey also identifies a significant adverse effect on other ED patient care and safety benchmarks, including consultant decision times and ED throughput. The end result is increased ED crowding and prolonged ED boarding, which have both been associated with increase patient morbidity and mortality.

From a quality of resident training standpoint, our survey also identifies concern that consultant providers may not be gaining the cognitive and procedural exposure needed to understand the nuances of care unique to the emergency department, broadly diminishing quality of training. We believe these concerns can be mitigated individualized standards.

Finally, ACEP believes that revised resident duty hours should be more flexible and better support the educational experience both at the individual resident level and at the program level.

While emergency medicine stakeholders believe that current DH standards foster a better work-life balance for residents, their lack of flexibility negatively impacts the learning environment and the educational experience residencies continuously strive to advance. It should go without saying that resident professional citizenship and vocational commitment are of high priority to both the ACGME and ACEP. It is core to our missions and essential to a well-rounded resident education. Current ‘one-size-fits-all’ DH standards, and their stringent enforcement, significantly limit a program’s ability to foster this citizenship and academic involvement.  This is due, in part, to the unintended ‘clock-punching’ mentality the current emphasis on DH tracking creates. But undoubtedly, this is also due to the large amount of administrative and time burden DH monitoring places on both the resident and program. ACEP implores the ACGME to explore means of infusing flexibility in applying and monitoring duty hours such that a program and resident can focus on the learning environment and not the clock or other administrative tasks.

In closing, ACEP believes the ACGME has the opportunity to revise DH in an individualized, and evidence-based, manner that advances patient safety and the learning environment.


ACEP Duty Hour Response to the ACGME

Dear Dr. Nasca:

The American College of Emergency Physicians (ACEP) received your request for our organization’s formal position on current ACGME resident duty hour requirements and their implications for cost, education and the working environment. We commend the ACGME for recognizing the importance of resident work hours as they pertain to domains of patient safety, resident wellness and the educational experience. We support the ACGME’s efforts to revise and refine the current work hour requirements utilizing a continuous improvement model.

As requested, ACEP will participate in the ACGME’s Second Resident Duty Hours in the Learning and Working Environment Congress to be held in March 2016. Below, please find ACEP’s organizational position and recommendations.

In preparing this response, ACEP convened a working group of twelve experts in medical education, each with extensive experience in graduate medical education (GME) in emergency medicine (EM). Additionally, many possess expertise in general GME and duty hours through leadership roles in their respective institutions. ACEP collaborated with the Council of Emergency Medicine Residency Directors (CORD) to conduct a robust survey of EM educators to gain a deeper understanding of the broader specialty perceptions of the impact of current ACGME duty hours on patient care, resident wellness, educational experience and residency and hospital costs. The results of this January 2016 survey will be used as supporting evidence for our recommendations.

ACEP’s formal position on the current ACGME resident duty hour requirements, including impact analysis, from our organization’s perspective, on costs and impact of implementation.

Formal Position:

  • ACEP supports resident duty hour requirements to improve patient safety, promote resident wellness, and enhance learning.
  • At present, ACEP has concerns about the impact of resident duty hour requirements on patient safety, quality of training, and costs.
  • ACEP believes resident duty hours should be revised to better support the educational experience.
  • ACEP believes that the ACGME should explore specialty-specific duty hour requirements for all specialties.

ACEP believes  residency training programs must be committed to promoting a supportive educational environment with resident well-being and patient safety as essential components. These must be balanced with maintenance of appropriate educational experiences if we are to train competent physicians. Current training standards in EM emphasize patient safety by requiring continuous on-site supervision of residents and mitigating resident fatigue. Resident fatigue has been addressed by restricting emergency department (ED) shift length and limiting consecutive days worked. These standards for EM are longstanding and suggest that uniform duty hour requirements may not be suitable for all specialties. (Wagner 2010) Further development of specialty-specific requirements may be beneficial.

At present, ACEP has concerns about the impact of resident duty hour requirements on patient safety, quality of training, and costs. Current duty hour standards aim to promote patient safety by minimizing medical errors made by fatigued resident providers. However, recent systematic reviews are mixed as to whether duty hour reforms improve patient care or resident wellbeing. (Bolster 2015, Lin 2015)  Specifically, while they have been effective at limiting long working shifts, there is concern that an increased number of handoffs occur resulting in less continuity of patient care and an increased risk of handoff-related medical errors. (Kogen 2006)  ACEP suggests teaching hospitals continue to design and implement structured processes for handoffs in order to ensure continuity of care and patient safety. Emergency medicine includes such training within their programs.

A second patient safety issue unique to EM is ED throughput. ACEP believes the current ACGME duty hour standards negatively effect ED throughput by increasing consultant decision times and prolonging times for admitted patients to be assigned an inpatient bed. Consultant decision time has been shown to be a significant contributor to ED length of stay. (Lee 2014) Furthermore, by limiting the availability of inpatient providers, hospital discharges are delayed and ED boarding increases. Previous studies concluded that ED boarding of inpatients increases patient morbidity and mortality. (ACEP 2008, Sprivulis 2006, Singer 2001)

The economic impact of duty hour reform has been substantial for EM. The significant economic impact for EDs has been the cost of replacing trainees who are pulled from ED rotations and repatriated back to their home residency programs in order to fulfill their service obligations. While there are no specific data to determine the amount lost, surrogate costs are available. For example, providing 16 hours of care daily by advanced practice providers (APPs) in the ED costs an organization approximately $500,000. We suspect that similar effects are felt in other specialties as their resident workforce hours are decreased. This results in less institutional funding available for educational programs without concomitant improvements in patient safety or training efficacy, as noted above.

The most significant economic impact of the duty hour rules for emergency medicine residency programs is the expansion of the administrative burden for logging and monitoring residents’ time. (Vidyarthi 2005)  Emergency medicine has had guidelines in place for decades that matched or exceeded the ACGME duty hour standards requiring almost no changes to the training environment for EM. Our specialty has done well with local monitoring systems. The required cost significantly increased with the expanded documentation and oversight required by both GME offices and residency programs. In some cases, compliance has required that programs purchase electronic management systems and devote faculty and administrator time to review and monitor data. It could be argued that savings from duty hours-related improvements in patient safety justify the personnel and administrative costs. However, since EM did not need to adjust duty hours, we did not appreciate any expected improvement in patient safety (and decreased cost of care) based upon duty hour changes. Thus, only the expense is found in EM. (Nuckols 2010)

ACEP’s formal recommendations regarding dimensions of resident duty hours requirements, and justification (wherever possible) for these recommendations with evidence.

Formal Recommendations:

  • ACEP supports the use of evidence-based resident duty hour dimensions to the end that they improve patient safety and resident wellness.
  • ACEP recommends that the ACGME revise the current dimensions to take into account the need for programmatic autonomy and flexibility germane to adult learning and professional development.
  • ACEP recommends absolving residency programs of the administrative burden of monitoring external moonlighting.
  • ACEP recommends that the ACGME revise these dimensions in a way that maximally promotes and fosters professional citizenship, patient accountability and academic service.

ACEP supports maintaining an educational environment that enhances patient safety and resident wellness while still maintaining important aspects of the educational experience necessary to prepare residents for the independent practice of medicine within their chosen specialty. While the identified ACGME dimensions of resident duty hours (eg, total weekly work hours, required time off and time between work responsibilities) are effective at promoting some of these goals in EM, ACEP believes that, as currently implemented and enforced, they unintentionally limit the programmatic and resident-level autonomy and flexibility germane to adult learning and career development. As such, ACEP recommends that there be greater flexibility within these dimensions to afford programs and residents the ability to balance educational program requirements (i.e., clinical versus non-clinical), academic pursuits, and personal career interests of individual residents.

Programs are tasked with preparing residents for the unsupervised practice of medicine. Part of this practice includes balancing and integrating clinical work, non-clinical obligations, and other opportunities in order to provide patient care, build expertise, and allow for individual personal and professional development. We believe current requirements around duty hour definitions and enforcement compromise a program’s ability to support and foster this development in EM and likely other specialties.

Physician burnout is a major challenge facing medicine.(Keller 1989)  While the duty hours were implemented to promote physician wellness and to prevent burnout, the current duty hour requirements have failed to reduce fatigue and burnout.(Ripp, 2015)  The reasons for the paradox are not clear, but it is likely multifactorial, and some authors believe this to result from excessive workload compression that stems from the current duty hours structure and tracking requirements. (Auger 2012, Hanna 2014)

Resident and faculty attendance at didactic conferences is critical.(Lefebvre 2013) Unfortunately, overlaying conference attendance requirements on the shift-based paradigm that is typically required to meet duty hour requirements dramatically decreases a program’s and resident’s ability to be flexible with educational or clinical time. By functionally locking a resident into very distinct work and didactic obligations with strict duty hour parameters, residents are not able to autonomously flex their time to promote personal or career development priorities or to address their personal learning needs. Residents have limited ability to move clinical shifts without violating duty hours or compromising conference attendance. Ideally, duty hour standards would afford programs and residents a degree of flexibility to allow individual educational experiences to be maximized.

Currently, programs must track a considerable amount of data to assure duty hour standards and other educational requirements are met. While the majority of this data is valuable and contributes to improved educational programs, patient safety in the learning environment, and resident wellness, some seem less relevant to these goals. Tracking resident time spent on activities that are not required by the ACGME or program inappropriately relieves the adult learner of responsibility to monitor their own well being, diminishing their ability to explore opportunities allowing for individualization in their training. We recommend maintaining the 60 hours per week scheduled ED shift maximum, but providing flexibility to the 72 hour rule if it is meant to encompass all outside activities. Additionally, allowing for averaging over 4 weeks in EM would be beneficial as it would allow residents more flexibility in scheduling.

In general, the current emphasis on duty hours de-emphasizes service and professional citizenship as an important component of the career of a physician. Though current requirements allow for exceptions when caring for a sick patient, the need to provide explanations for these exceptions imposes an additional burden on the residents, often resulting in a punitive effect rather than applauding the principle of “responsiveness to patient needs that supersedes self-interest” as stated in the ACGME requirements (IV.A.5.f.2). (ACGME 2013)  Germane to this issue is the resultant increased resident handoffs that also impact the resident education experience by limiting their exposure to the continuum of patient care.

While duty hour limits serve an important purpose, allowing a more flexible structure would still meet the spirit of the rule while facilitating individualization of education and deliberate practice with time management. The short term potential impact of duty hours on resident wellness may have unintended negative effects on long term wellness as residents are not exposed to the realities of all that encompasses medical practice.

ACEP’s formal recommendations regarding standards governing key aspects of the learning and working environment, and justification (wherever possible) for these recommendations with evidence.

Formal Recommendations:

  • ACEP supports efforts to study the effects of relaxing duty hours monitoring and reporting.
  • ACEP recommends that all trainees not on EM rotations be limited to 24 hour continuous scheduled duty hours, regardless of their level of training.
  • ACEP supports a minimum rest interval between duty hour periods for shifts twelve hours or less, and a 14-hour rest period after shifts exceeding 24 hours.
  • Rotating residents should be subject to the duty hour standards of the host rotation program.

In a recent review (Bolster 2015) and in a formal response to an ACGME duty hours task force request for specialty feedback prior to the 2011 standards (Philibert 2011, Wagner 2010), EM made several recommendations across the three domains primarily affected by those reforms. Emergency medicine educators and leaders were recently surveyed regarding the impact of duty hour reforms across similar dimensions.

Respondents perceive that duty hour requirements have had a negative impact in the following areas:

  • consultant to consultant handoffs,
  • consultant competency to provide requested service in the ED,
  • ED length of stay, ED boarding, and
  • consultant cognitive and procedural competency.

In addition, the ability of programs to deliver an effective didactic curriculum has been negatively affected as has overall professional citizenship and accountability. In fact, the only areas of perceived positive impact as a result of duty hour reform were resident work-life balance/wellness and a program’s ability to foster it.

As others have suggested, we support more research studying the effects of relaxing the duty hours monitoring and reporting process.(Lin 2016) The additional administrative requirements for tracking, both by programs and residents themselves, has led to lower job satisfaction and increased costs associated with hiring staff devoted to monitoring resident duty hours. The burden of tracking has contributed to the erosion of professionalism as residents pay more attention to “clocking in” and “clocking out.”

Duty hour duration caps (ie shift length), inclusive of PGY-1 level trainees, have had mixed effects on patient safety and medical errors.(Lin 2016)  Intuitively, there may be a positive effect on resident fatigue with shorter shifts; however, data are inconclusive.(Bolster 2015, Desai 2013, Hanna 2014, Sen 2013)

Educator perception is that schedule flexibility and conference attendance has been negatively affected by duty hour reforms. Shorter shifts lead to more care transitions (ie, handoffs). Indirectly, ED length of stay and boarding have increased.(Philibert, CORD survey results)  Emergency medicine shift durations have long met the IOM and ACGME standards, balancing clinical growth and responsibility with patient and resident safety.

However, non-emergency medicine (ie, consultant) trainees’ shift length restrictions negatively impact patient flow in the ED by requiring more handoffs and creating barriers to efficient patient care.(Schuh 2011, Schwartz 2013, Sussman 2015)  By applying the same PGY-2 and above shift duration limit to PGY-1s, trainee education would be enhanced and there would be a positive trickle-down effect that would improve patient care in the ED. We therefore recommend that all trainees not on EM rotations be subject to the 24 hour continuous duty rule, regardless of level of training.

Some specialty review committees (RCs) such as internal medicine require their residents to follow their RC standards even when rotating on other services. This leads to lost clinical opportunities for those residents, and scheduling and clinical inefficiencies for the host program. We recommend that residents should be permitted to follow the host program’s duty hour standards such that a safe clinical environment and educational atmosphere can be maintained. The host RC is best suited to understand the learning environment, patient safety issues and duty hours unique to that rotation than are other specialty RRCs.

There is a benefit to resident wellness and safety by mandating a minimum rest interval between duty periods. The longer the duty cycle—especially with night float or overnight long-call work—the longer the rest interval should be. However, shifts in emergency medicine training programs are already limited to 12 hours of scheduled duty. Requiring a rest interval equivalent to the duty period can be a barrier to schedule flexibility and conference attendance. Establishing a fair but more realistic minimum rest interval would re-establish a balance between resident wellness, clinical experience, and education. We support the 14-hour rest period after a long-call (eg, 24˚+4˚) shift.

 

References
Wagner MJ, Wolf SJ, Promes S, et al, Duty Hours in Emergency Medicine: Balancing Patient Safety, Resident Wellness, and the Resident Training Experience: A Consensus Response to the 2008 Institute of Medicine Resident Duty Hours Recommendations. Acad Emerg Med. 2010;17(9):1004-11.

Bolster L, Rourke L. The Effect of Restricting Residents’ Duty Hours on Patient Safety, Resident Well-Being, and Resident Education: An Updated Systematic Review. Journal of Graduate Medical Education. J Grad Med Educ. 2015;7(3):349-63

Lin H, Lin E, Auditore S, et al. A Narrative Review of High-Quality Literature on the Effects of Resident Duty Hours Reforms. Acad Med. 2016;91(1):140–50.

Lee PA, Rowe BH, Innes G, et al. Assessment of consultation impact on emergency department operations through novel metrics of responsiveness and decision-making efficiency. CJEM.2014;16(3):185-92.

Kogan JR, Pinto-Powell R, Brown LA, et al. The impact of resident duty hours reform on the internal medicine core clerkship: results from the clerkship directors in internal medicine survey. Acad Med. 2006;8(12):1038-44.

American College of Emergency Medicine Task Report of Boarding, Emergency Department Crowding: High-Impact Solutions. 2008: Irving, TX. http://www.acep.org/workarea/DownloadAsset.aspx?id=50026. Accessed on January 22, 2016.

Sprivulis PC, Da Silva JA, Jacobs IG, et al., The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust. 2006;184(5):208-12.

Singer AJ, Thode HC, Viccellio P, et al. The association between length of emergency department boarding and mortality. Acad Emerg Med. 2011;18(12):1324-29.

Vidyarthi A, Auerbach A. Is 80 the Cost of Saving Lives?  Reduced Duty Hours, Errors and Cost. J Gen Intern Med. 2005;20(10):969-70.

Nuckols T, Escarce JJ. ACGME Common Program Requirements: Potential Cost Implications of Changes to Resident Duty Hours and Related Changes to the Training Environment Announced on September 28, 2010. https://www.acgme.org/acgmeweb/Portals/0/PDFs/dh-CostAnalysisfor2011CPRs%5B1%5D.pdf. Accessed on January 22, 2016.

Keller KL, Koenig WJ. Management of stress and prevention of burnout in emergency physicians. Ann Emerg Med. 1989;18(1):42-7.

Ripp JA, Bellini L, Fallar R, Bazari H, Katz JT, Korenstein D. The impact of duty hours restrictions on job burnout in internal medicine residents: a three-institution comparison study. Acad Med. 2015;90(4):494-9.

Auger KA, Landrigan CP, Gonzalez JA. Better Rested, but More Stressed? Evidence of the Effects of Resident Work Hour Restrictions. Acad Ped. 2012;12:335-343.

Hanna J, Gutteridge D, Kudithipudi V. Finding the elusive balance between reducing fatigue and enhancing education: perspectives from American residents. BMC Medical Education. 2014;14(Suppl 1):S11.

Lefebvre C, et al. Increasing Faculty Attendance at Emergency Medicine Residency Conferences: Does CME Credit Make a Difference. JGME. 2013:Mar;41-45.

ACGME. ACGME Program Requirements for Graduate Medical Education in Emergency Medicine. 2013. http://www.acgme.org/acgmeweb/portals/0/pfassets/2013-pr-faq-pif/110_emergency_medicine_07012013.pdf . Accessed on January 22, 2016.

Philibert I, Amis S. ACGME Task Force on Quality Care and Professionalism. 2011. https://www.acgme.org/acgmeweb/Portals/0/PDFs/jgme-monograph%5B1%5D.pdf. Accessed on January 22, 2016.

Desai SV, Feldman L, Brown L, et al. Effect of the 2011 vs 2003 Duty Hour Regulation–Compliant Models on Sleep Duration, Trainee Education, and Continuity of Patient Care Among Internal Medicine House Staff. JAMA Intern Med. 2013;173(8):649–7.

Sen S, Kranzler HR, Didwania AK, Schwartz AC, Amarnath S, Kolars JC, et al. Effects of the 2011 Duty Hour Reforms on Interns and Their Patients. JAMA Intern Med. 2013 Apr 22;173(8):657–6.

Schuh LA, Kahn MA, Southerland AM, et al. Pilot trial of IOM duty hour recommendations in neurology residency programs: unintended consequences. Neurology. 2011;77(9):883-7.

Schwartz SI, Galant J, Kaji A, et al. Effect of the 16-hour work limit on general surgery intern operative case volume: a multi-institutional study. JAMA Surg. 2013;148(9):829-33.

Sussman D, Paul JE. The impact of transitioning from a 24-hour to a 16-hour call model amongst a cohort of Canadian anesthesia residents at McMaster University. Adv Med Educ Pract. 2015;7(6):501-6.

Stephen Wolf, MD, FACEP

Stephen Wolf, MD, FACEP

Associate Professor of Emergency Medicine | University of Virginia
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