Perceived Impact of Proposed Institute of Medicine Duty Hours on Family Medicine Residency Programs

The ACGME is faced with an enormous challenge. On the 25th anniversary of the Libby Zion case¹ and the 5th anniversary of the ACGME Duty Hours,² the Institute of Medicine (IOM) released a December 2008 report calling for a revision in duty hours and trainee supervision.³ The ACGME is asking the graduate medical education community to collaboratively address concerns raised by the IOM about resident schedules and safety of patients and trainees. In discussions following the release of the IOM report, opportunities for improvement as well as threats to the educational process and the viability of some residency training programs have emerged.

The Association of Family Medicine Directors (AFMRD) surveyed its membership utilizing an online survey instrument (Zoomerang). As of February 26, 2009, 60% of the program directors responded to the survey. This represents a broad representation of programs by geographic region, community type (rural, suburban, urban), program administration, and program size.

The results of this survey clearly identify numerous issues regarding implementation of the IOM recommendation. For instance, two-thirds or more of the program directors responded that it would be “very easy” or “easy” to implement:

• In-hospital call every third night, no averaging

• 10 hours off after day shift

• Internal and external moonlighting within the 80-hour weekly limit

Furthermore, two-thirds or more of the directors responded that it would be “difficult” or “very difficult” to implement:

• Ensuring a 5-hour protected sleep period between 10 PM and 5 AM in a 30-hour period

• Limiting residents to a 16-hour shift

• 12 hours off after night shift

• In-hospital night shift 4-night maximum; 48 continuous hours off after 3 or 4 nights of consecutive duty

• 5 days off per month; 1 day (24 hours) off per week, no averaging; 1 48-hour period off per month

In addition to the difficulties noted with implementation, the residency program directors expressed concern regarding detrimental effects on medical education as well as potential decrease in the quality of care provided. Over 90% of the program directors expressed concerns about:

• Graduating doctors who generally take less ‘ownership’ and do not know patients as thoroughly as in the past

• Residents developing a ‘shift-worker mentality’ that the IOM rules would exacerbate

• Future doctors being less prepared for the work-hour demands of practice

The untoward effect of the proposed changes in work hours was reflected in the finding that two-thirds or more of the program directors believe that implementation of the IOM recommendations would NOT:

• Improve patient safety

• Improve resident education

• Produce more compassionate and more effective family physicians

Finally, nearly two thirds believe that:

• In their own institution, implementing the requirements would result in decreased patient access to care

• Implementing IOM requirements would result in graduating doctors who are not experienced enough to practice independently

• If the IOM duty hour recommendations are implemented, family medicine training may need to add an additional year of training

The program directors also expressed significant concerns regarding financial issues as well as transferring the work associated with patient care to other healthcare professionals with either less extensive training or to individuals who are not governed by work duty hour restrictions:

• Nearly one-fourth of all program directors responded that full implementation would threaten their program’s viability.

• Two thirds of program directors anticipated that implementation could only be accomplished with more resources (personnel, faculty, finances).

• Over one-half of program directors estimated the additional annual financial cost for program implementation of the recommendations at >$100,000.

• Over 70% responded that the minimum time period notice needed before the IOM recommendations could be realistically implemented at >12 months.

To assist the ACGME, the AFMRD Board believes that the following principles should govern any decision regarding implementation of the proposed IOM recommendations or any other further restrictions:

• No evidence exists that current duty hours have reduced errors.

• Any new duty hour rules should be evidence based and validated by a series of observational studies designed to detect the intended and unintended impact of the proposed limitations on duty hours.

• Every residency program must focus on appropriate resident supervision to reduce inevitable errors of resident training.

• Any efforts to reform duty hours should not further threaten the ability to produce the number of family physicians needed to serve the country.

Family medicine welcomes the opportunity to participate in this important dialogue, which must protect patient safety and resident well being, while maintaining excellence in education.

• © 2009 Annals of Family Medicine, Inc.