I clearly remember the last night of my first rotation as a medicine intern. I had been on call the night before and admitted several new patients overnight to my already busy service in the Medical ICU. I still had to sign out my patients to the intern taking over my service the next day, and it was about 8 p.m. when he finally got tired of waiting for me to page him and just showed up in the MICU to find me preparing to intubate a patient in respiratory distress. I remember starting the sign out as I was doing the intubation and stopping to check that I had in fact intubated the trachea—I can’t to this day recall where my resident was at the time—and not the esophagus, before continuing. I’d come on service at around 6 a.m. the day before, and this was my first month of internship. Many practicing anesthesiologists today will have a similar experience to share…war stories from the trenches.
In recognition of increasing public concern about patient safety and the growing concern that long resident work hours could affect natural work-rest cycles, changes were advised. After a Task Force review in 1988, the ACGME first took the position that the primary objective of residency is education, which must be balanced with the needs of patient care. The Council went on to recommend, among other things, 1 day off in 7 for physicians in training. The ACGME recommendations have since been further refined and codified, and in 2003 the first in a series of progressively stricter guidelines for the hours and conditions under which residents may work was implemented. The guidelines have been modified and, in fact, made more stringent since then, most recently with regulations adopted in July 2011. As the accrediting body for graduate medical education (GME) in this country, it is generally accepted that ACGME requirements are sacrosanct among training programs.
For those of you who have not been involved in an academic training programs for the past five or ten years, you may need to sit down before you keep reading because I am about to explain the current system of rules that govern residency training in anesthesiology and you may be surprised to read what follows:
The ACGME now requires residents: to have at least 1 day out of 7, averaged over 4 weeks, free from any type of call and off-pager; to have at least 8 hours and preferably 10 hours off between shifts; to work no more than 80 hours per week, averaged over 4 weeks; interns may work no more than 16 hour shifts and must have direct (in-house, immediately available) attending supervision while more senior residents can work at most 24 hours on in-house call with 4 additional hours designated for transfer or completion of patient care but with NO new patient care responsibilities.
While working within the duty hour limits, residents must log not only their shifts but also the specific mix and number of required cases and demonstrate competency in the six major areas required by the ACGME:
patient care, medical knowledge, professionalism, interpersonal skills and communications, systems-based practice, and problem-based learning.
One critical aspect of residency training that the most recent guidelines explicitly recognize is the need for progressive responsibility and increased autonomy as residents become more senior while at the same time balancing patient safety. This important objective was eloquently presented by ACGME CEO Thomas Nasca in an open letter to the greater GME community in October, 2009. The ACGME recognizes that after training, physicians may not have the benefit of taking an 8 to 10 hour break or stopping care of a patient after 24 hours so the rules have been made more flexible—and specialty dependent—for senior residents so that they can experience and learn what they will face upon graduation.
After graduation, residents in training today will face the challenges we have all faced at some point, working long hours, sometimes while tired. They may find that they are not relieved for lunch or after a regular shift, especially when the case is complex. They may be asked to work after being up all night as not all practices can afford to staff for what may be a rare emergency case. They must be not only well trained clinically but also professionally so that they are able to meet these challenges in a way that is cooperative within their practice group while managing the need for their well being and patient safety. These are challenges we all face in our practice as anesthesiologists at some point.
As an academic physician, I do sometimes worry that in satisfying both the spirit and letter of the ACGME rules, I may be giving my residents an idealized picture of what they will encounter upon graduation. Hopefully, by increasing the exposure residents have to handling more patient care responsibility over time, by having them work with the generous private-practice physicians who volunteer as teachers and by offering practice panels that allow residents the opportunity to talk in an open format about “real world” anesthesia, our residents will be able to hit the ground running when they graduate. As educators we would like to ensure that our residents will be well prepared for practice, but it is also important that those of us who have been out of residency to recognize that the training today, while perhaps more restrictive in some ways, is also more sophisticated in others.
Do I think that residents today would be better off having shared my experience one month into internship of signing over my service of patients after being on duty for 38 hours? I would say, emphatically, no, they would not. These work limits will surely shape the expectations of future anesthesiologists but hopefully in a way that improves their patients’ lives as well as their own.
For more information on the ACGME guidelines, including a detailed description of the development of the current guidelines, relevant literature, and a cost analysis please see the following resources: