Local, State, Federal
What?s Right for Residents?
Radiology Responds to IOM New Duty Hour Recommendations
Are physician residents in training programs getting enough sleep, time off, and supervision? Congress thinks not. As a result, it asked the Institute of Medicine (IOM) to review physician residency program guidelines. The recently issued recommendations are intended to improve patient safety and prevent medical errors through stricter duty hour limits, more sleep time, and improving supervision.1
The main body that oversees resident duty hours is the Accreditation Council for Graduate Medical Education (ACGME). In the course of ACGME’s review of the IOM recommendations, representatives from each specialty have been asked to comment on the proposed changes, which were published in 2008.
In the case of radiology, a panel composed of the American College of Radiology, the American Roentgen Ray Society, the Radiological Society of North America, and other radiology societies reviewed the recommendations and responded on behalf of radiologists.
A summary of the response was published in the January issue of the Journal of the American College of Radiology.2 The lead author of the summarized response is Martha B. Mainiero, MD, a radiologist at the Warren Alpert Medical School of Brown University, Providence, RI, and a member of the board of directors of the Association of Program Directors in Radiology.
In an interview with Axis Imaging News, Mainiero said that the most significant change for radiology would be in the area of night shift duty hours and days off. The IOM would limit the number of night shifts in a row that a resident could have under the new provisions. The IOM is recommending a 4-night maximum with 48 hours off after 3 or 4 nights of consecutive duty. The radiology committee suggested the maximum be 5 or 6 consecutive shifts, followed by 48 hours off.
Although the radiology committee understood the intention to decrease fatigue, the committee thought that the 3- or 4-night limit would actually be worse for fatigue and for resident education. Mainiero explained that many residents have told her that they are most tired the first night switching over to nights and that it takes 2 days to get acclimated to night shift work.
“Every single resident I’ve asked and every program director I’ve asked have said that they really feel like it would be better to continue to work at least 5 to 6 nights of night shift and get it all over with. Then they could have some recovery time and switch back to day.”
Mainiero added that having 2 days off after three shifts would mean being away from the hospital more often, making residents miss more daytime and weekday educational activities.
According to current ACGME guidelines, the maximum shift length is 30 hours. Residents can see new patients up to 24 hours into the shift, and then have 6 additional hours for transitional and educational activities. The proposed IOM regulations would still maintain the 30-hour limit, but residents could see new patients only up to 16 hours instead of 24. They would also be required to have a subsequent 5-hour protected sleep period between 10 pm and 8 am. As before, the remaining hours within a maximum 30-hour shift would be reserved for transitional and educational activities.
The radiology committee report disagrees that there should be a protected 5-hour sleep period because of patient continuity issues and for practical reasons.
Mainiero said, “If you can’t call them with a question or wake them up and look at an x-ray, why bother? You might as well send them home, which means you will have to have many more shifts and more coverage. So, the committee really thought that was an impractical recommendation.”
The committee agreed with the IOM recommendation that there should be more focus on supervision. (See summary chart (PDF) for a brief description of differences and recommended changes.) However, the committee members suggested that a supervisor using teleradiology should count as being “on-site.”
The committee also agreed that residents should have one 48-hour period off per month, but disagreed with the change of 1 day off per week, not averaged over the course of a month. Currently, residents have only a minimum of 1 day off in 7, averaged over a month. Without averaging, said the committee, scheduling would not only become more difficult, but residents would be less able to take long weekends or arrange more consecutive 48-hour periods.
The committee also agreed that resident moonlighting should be counted toward 80-hour maximum duty hours, but pointed out that enforcing this provision requires residents to be more forthcoming about their moonlighting.
If the recommendations are adopted by the ACGME, Mainiero noted that there would be a higher cost to facilities and residency programs, especially if the protected 5-hour sleep time is implemented.
She said, “Someone is going to have to do that work that is now done by the residents, so that would be number one. Then in some situations, there would be a cost educationally to residents if they’re going to be off away from services more. But mostly it’s going to be a monetary cost. You just have to hire more physician assistants, more nighthawk, or something to cover for the work done by residents.”
Asked about the tradition of residents covering night shifts, Mainiero commented that to some degree it makes sense: the younger you are, the easier it is to work at night.
She added that night shifts are also when residents have the opportunity to learn the most through their independence. “When you’re working with a resident, whether it’s daytime or nighttime, if you’re there, the residents act differently. They don’t make the final decision. You’re sitting right there during the day. They don’t pass that ultimate test of knowing they can do it and function independently until they’re given that kind of independent experience at night.”
—Tor Valenza
References
- Ulmer C, Wolman DM, Johns MME, eds. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington, DC: National Academies Press; 2008.
- Mainiero MB, Davis LP, Chertoff JD. Resident duty hour limits: recommendations by the IOM and the response from the radiology community. J Am Coll Radiol. 2010;7:56-60.
