CIR has been a leading advocate for duty hours reform for more than 40 years. We have always emphasized the need to improve the learning environment and ensure a good work-life balance. Who understands better than residents the negative effect that sleep deprivation has on our ability to deliver quality care to our patients and also to care for ourselves? Historically, the mere mention of duty hours limits has evoked strong opinions within academic medicine, fueled most recently by two controversial studies that seek to roll back the ACGME’s 2011 hours limits.
The ACGME hosted a Duty Hours Congress in March 2016 to assess the current rules. Here are the key takeaways from our ACGME testimony:
CIR is not calling for an end to 24+4 hour shifts. We recognize that many medical educators are convinced of their value and that every specialty is different. However, we do recommend that more rigorous safeguards be put in place to ensure patient safety, maximize the resident learning experience, and minimize fatigue and burnout. Safeguards should include reducing on-call responsibilities, mandatory and enforced breaks for rest and/or sleep, and further limits on the number of extended on-call shifts permissible in any given rotation. We also recommend transparency and public reporting of the residency programs that currently schedule residents to work long call shifts of 24 or more hours.
Tackle the root causes of resident un-wellness. Three resident suicides within a few weeks of each other in 2014 brought national attention to the problem. We join the ACGME in urgently calling for a focus on wellness that involves understanding its causes and making meaningful changes to address it. Significant change would include the following:
• Guarantee a minimum of 5 days off per month with no averaging, and including one full weekend off. Not having adequate time for rest and rejuvenation, family and friends is a huge contributor to stress and burnout. The current rules allow for 1 day off per week, averaged over 7 days, which often means residents work 14 consecutive days. Many residents work weeks – even months – without a free weekend.
• Ensure teaching hospitals provide adequate ancillary service staffing. Many residents today still spend extra hours in the hospital each day transporting patients, tracking down labs, drawing blood, putting in IVs, or discharge planning; work which could and should be done by other staff. This extra work takes away from resident learning and the time we spend at the bedside; and worse, it adds significantly to resident cynicism and burnout.
• Establish safe and sustainable resident workloads, for example limits on patient admissions and the number of patients a resident must cross-cover while on-call. Residents should not be put in a position where they are expected to provide safe, high quality care under impossible circumstances. This too leads to stress and burnout, not to mention preventable medical errors.
• Collect concrete data on resident car crashes, needlestick injuries and burnout as part of each institution’s Clinical Learning Environment Review (CLER) visit. Residents need to know that the ACGME is paying attention to their safety.
• Mandate clinical work and learning redesign with a focus on those rotations that residents identify as the most grueling or those with the least educational value. Using the tools of quality improvement, residents can lead the way in identifying changes that will significantly improve the clinical and learning environment. Best practices exist and should be publicized so others can learn.
• Highlight the medical educator innovators who have already made significant changes to improve patient safety, resident learning, and satisfaction. They exist and their best practices should be widely shared.
• Do not weaken the current duty hour limits. Trials like FIRST and iCompare were deliberately designed to demonstrate that no difference exists in patient outcomes between residents who work 16 or 30 consecutive hour shifts. This is a misguided approach to improving patient care and resident wellbeing. Supporting these studies misleads the public and does an injustice to residents and fellows. The ACGME should instead be examining what can be done to redesign clinical training in fewer hours, improve the educational value of those hours and guarantee the safety and wellbeing of the residents who are working them.
• Make the business case for change. CIR recognizes that change is difficult but we are heartened by the residency programs which have already begun to make this leap. Work and learning redesign means working “smarter” and that often brings with it savings in efficiency and effectiveness along with increased patient and resident satisfaction. The business case for redesign — and additional resources when necessary — can and must be made to hospital management. The ACGME should assist programs to do just that as part of their CLER process.