Between a Rock and a Hard Place: ACGME Passes New Duty Hour Regulations

Yesterday, the ACGME officially approved new duty hour regulations to be effective July 2011. The initial proposals have been a hot topic of discussion since they were first introduced in June. Read a prior post, Resident Duty Hours: Loopholes in the New Regulations, for a more detailed analysis of the fine print. The current interns and second year residents are now officially “the residents who got the short end of the stick.” No one seems to care. We labored through intern year and we survived. Yes, it was difficult, but we made it. So did all of our predecessors. And now we are limiting hours to “protect” interns – we are switching the pyramid such that senior residents, rather than interns, are spending more time in the hospital. The senior residents, PGY-2 and above, will now be required to stay for 24 hours – the interns must leave after 16 hours.

Great idea in theory, but far more difficult in practice. Hospitals across the country are going to struggle to comply with these new regulations. Options include switching to a night float system, bringing in more hospitalists and PAs, or – and this seems like the least reasonable, but the most likely – just let the senior residents sweat it out. They can deal. Right…

I am curious how many people who sit on the ACGME board were interns when the new computer order systems began to replace handwritten charts. With the advent of computer ordering, residents are more closely monitored and are required to place electronic orders in a timely fashion – or else. I cannot count the number of times that I have been running a code, intubating a patient, placing an urgent central line – and have been interrupted because I need to find a computer to type in a laundry list of orders. Regulations and systems can be helpful – but they become a problem when they are so cumbersome that they compromise patient care.

And this is where the intern comes into play. Although the job of an intern is tiring because of the hours, it is not overwhelmingly difficult from an intellectual standpoint. An intern can always ask for help. As senior residents, however, we rely on interns to help us with some of the more mundane tasks – order writing, note writing, etc. Although these tasks may seem mundane, (1) they are important and (2) in retrospect, I realize that I learned a lot from them – by directing a patient’s care on the micro level, even if I am only writing orders that someone else has instructed me to write, I gained substantial amounts of medical knowledge during my intern year by doing, rather than by reading or thinking.

Another problem is that second year is not easy. Do the board members remember what it was like to be a second year resident, and do they have a sense of what it is like now? I worked as an intern in the medical intensive care unit in my last month of intern year, and one month later I worked as the senior resident in the coronary care unit. Which was harder, and which did I need to be less fatigued for? Most definitely the latter. In those first months of second year, fresh out of intern year, residents run the intensive care units, the emergency department, the medical floors. And it is important that we have time to think. If we are bombarded with our job as a senior resident and the tasks of the intern – order writing, note writing, etc. – we cannot do either well. In a 24-hour time period, it is the senior resident – more than the intern – who needs a short nap. After all, the seniors – not the interns – should be the ones making critical decisions about patient care in the middle of the night.

The 24-hour rule has also been changed with these new regulations, from 24 hours of patient care plus 6 hours of transfer of care to 24 hours of patient care plus only 4 hours of transfer of care. I find it almost comical that we are going to try to cut hours in the intensive care units, where rounding on new patients can take until noon or beyond – which far exceeds the proposed limit. The loophole I mentioned before – that residents can stay later to take care of one patient – is going to be used to excess, and not necessarily for the right reasons. There is no possible way to finish medical rounds earlier than we do on post-call days. Programs are already struggling to meet the current work-hour regulations.

Good ideas in theory are not always good ideas in practice. Although the ACGME has good intentions in mind (I agree with the principles behind them), the hospitals are left to fend for themselves. With limited money and limited residents, these new regulations put hospitals between a rock and a hard place. And ultimately, that will put senior residents in a difficult situation. I hope that implementation of these new policies will be a matter of concern – it is easy to publish guidelines, but much more difficult to execute them appropriately.


One Response to Between a Rock and a Hard Place: ACGME Passes New Duty Hour Regulations

  1. Dr. Dredd says:

    I don’t sit on the ACGME board, but I was an intern when my hospital rolled out computerized order entry. It was a disaster at first. I remember writing an entire set of admissions orders, only to have the computer crash when I tried to sign them. After that, I signed every single order after writing it, so that I wouldn’t have to re-input the entire set at the end.

    Not a fun time.

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