Wednesday, March 15, 2017

ACGME Increases Shift Length For Interns

The American Council of Graduate Medical Education, or ACGME, recently announced that it was reversing course and lengthening the longest shift an intern can work in a hospital from 16 to 24 hours. The ACGME governs the structure of all accredited residency training in the United States, so this change will have broad-ranging effects. While PGY-2 residents and above were already allowed to work these longer shifts, interns had been protected from them since 2010. Here are various summary articles:

However, since 2010, concerns have arisen that the shortened shift actually detracts from intern training as they are required to hand off patients frequently in order to abide by the 16-hour restriction. Often times, a complex patient may require care past the 16 hour mark, which the trainee could not participate in while still complying with the rule.

Another concern was the hand-offs themselves. Especially in July, interns are still learning how to manage patients on a very basic level. Asking them to hand off a complex patient to another intern at the same early training stage is a recipe for error, since clinically relevant information may be omitted or underplayed, leading to errors in the provision of care.

Ostensibly, the ACGME attributes its change to the following reasons:
In keeping with this philosophy, the changes are supported by testimony from a wide range of physician specialty educators and intended to:
  • place greater emphasis on patient safety and quality improvement;
  • more comprehensively address physician well-being;
  • strengthen expectations around team-based care; and,
  • create flexibility for programs to schedule clinical and educational work hours within the maximums currently utilized in the US.
These revisions were developed as part of the ACGME’s periodic review of all program requirements to ensure that professional preparation of physicians adequately addresses the evolving and growing needs of patients. 
The trade-off though is a return to the era of the over-worked, fatigued intern. Historically, residency was a brutal training process with no restrictions. The first attempt to curb work hours was set in motion by the death of Libby Zion, an 18 year old girl who was under the care of minimally supervised, overworked trainees. Her father Sidney's anger at her death led to the ACGME instituting its first series of work hour reforms. Even those changes were slow to come around: the commission formed after Zion's death recommended changes including an 80 hour work week restriction in 1989; the ACGME instituted those changes in 2003, fourteen years later.

There have been several minor revisions since 2003, including the move to the 16 hour intern limit in 2010. The debate will continue over striking the appropriate balance between clinical exposure and the physician's personal health. As a medical student, you should inquire with prospective training programs about how they plan to manage the change, as well as ask current program trainees how the program actually functions. In more demanding specialties, such as neurosurgery or orthopedics, there are many programs that have trainees working longer than the hours they actually log. Ultimately, the ACGME is not an enforcing body and cannot assess whether each resident actually works the number of hours they say they do, so it is up to you to ensure the training program you join matches your expectations.

Regardless of whether you join a relaxed program or a stressful one, your best bet to make sure you are as prepared as possible to handle patients clinically on your own. Despite different specialties, intern experiences have a lot of overlap. The following resources below should help you be better prepared for the first day when you round by yourself as a full MD:

  • Pocket Medicine by Marc S. Sabatine
    A handy guide that easily fits into a white coat pocket, Pocket Medicine has long been essential reading for interns, especially those on medicine wards. This small book is chock full of practical tips and broad differentials for common clinic findings.

  • First Aid for the Wards by Tao Le, Vikas Bhushan, et al.
    From the authors of First Aid for USMLE Step 1, the bible of Step 1 prep, comes this book about rotation-specific advice. While intended for MS3 students, it still contains lots of useful information for interns, especially those who will rotate among various specialties, such as transitional interns.

  • Intern by Sandeep Jauhar
    While not a technical guide like the two prior books, this memoir by Dr. Jauhar gives a good sense of what it feels like to be an intern, especially the sense of disorientation one may feel at times.

Good luck! If you are or recently were an intern, what was your experience like? What do you think of the proposed changes?

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