Late last year, the Accreditation Council for Graduate Medical Education (ACGME) issued proposed revisions to the Common Program Requirements for residency and fellowship training.
At the heart of the proposed new requirements is this philosophy: Residency education must occur in a learning and working environment that fosters excellence in the safety and quality of care delivered to patients today and in the future. The important corollary is that physician well-being is crucial to their ability to deliver the safest, best possible care to patients.
In keeping with this philosophy, the proposed changes to the Common Program Requirements would:
- place greater emphasis on patient safety and quality improvement;
- more comprehensively address physician well-being;
- strengthen expectations around team-based care; and,
- streamline resident clinical and educational work hours to be consistent across the country in a framework that is supported by testimony from educators.
The public response to the proposal has focused largely on a single issue — allowing first-year residents to be scheduled for up to 24 hours. This is an important change from current requirements, and merits public comment, which the ACGME welcomed along the way. Even so, it is only one of many changes laid out in 20 pages of proposed revisions that, taken together, aim to improve both patient safety and physician well-being as we train the next generation of physicians. This larger context warrants greater attention. The ACGME is charged with the oversight of the professional preparation of physicians, which changes as times and needs evolve. These proposed changes arose from the ACGME’s periodic review of residency program requirements. They were not arrived at lightly. The review was initiated in 2015 and, over the last year, a Task Force reviewed the published scientific literature on the impact of standards on the quality and safety of patient care, resident well-being, and resident and fellow clinical care and education hours.
The Task Force also looked at new research from the past five years, including relevant multicenter research trials, as well as position statements from more than 120 organizations and individuals, including specialty societies, certifying boards, patient safety organizations, resident unions, and medical student organizations. In March of 2016, a national meeting was convened to let Task Force members hear comments from these organizations, experts, and members of the public to inform their deliberations.
New Requirements Would Keep Training In Step With The Way Care is Delivered Today
The necessity for physician education to emulate real-world practice cannot be overemphasized. Just as drivers learn to drive under supervision on the road, residents must prepare in real patient care settings for the situations they will encounter after graduation.
That means residents and faculty members should be working in a well-coordinated team, using shared methodologies—such as consistent reporting and disclosure of adverse events and unsafe conditions—to achieve institutional patient safety goals. What is more, residents must develop the skills and the confidence to manage challenging situations, under supervision, and must learn to care for patients over extended hours, and during night-time hours, because these are circumstances they will encounter after graduation. Neurosurgeons routinely encounter patients with serious injuries or illnesses whose surgery and post-operative care require them to work well beyond 16 hours. At some point in their clinical practice, physicians who care for these patients will need to put in these kind of hours.
At the same time, the proposed requirements also recognize the significant risk of burnout and depression for physicians. They stress the need for both programs and institutions to prioritize physician well-being, ensuring protected time with patients and minimizing non-physician obligations. This reflects our mutual obligation to help physicians find meaning and joy in their work, and to provide them with the resources necessary to care for themselves as well as their patients.
It is with these two goals—giving students realistic practical experience and protecting their well-being—in mind, that the new proposed requirements would change the current standard limiting first-year residents to 16 hours of clinical experience and education.
The new cap would be 24 hours for all residents, plus four hours to manage transitions in care. This puts first-year residents on the same schedule with other residents, and is a commitment to team-based care and seamless continuity of care that promotes professionalism, empathy, and commitment among new physicians.
It is important to note that 24-hours is a ceiling, not a floor, and most medical residents won’t experience a 24-hour clinical work period. Individual specialties have the flexibility to modify these requirements to make them more restrictive as appropriate, and in fact, some already do. As in the past, it is expected that emergency medicine and internal medicine will make individual requirements more restrictive. Currently, emergency medicine has more restrictive requirements on consecutive hours scheduled, and internal medicine does not permit averaging of the frequency of overnight call.
It is particularly worth noting that the new requirements do preserve core elements from the 2003 and 2011 ACGME Requirements that cap the total number of clinical and educational hours for residents, based on a framework, averaged over four weeks, of:
- a maximum of 80 hours per week;
- one day free from clinical experience or education in seven; and,
- in-house call no more frequent than every third night.
Finally, we’ve also begun to revisit how our organization communicates its key priorities and values. What may come across to some as minor changes in the language used in the revised standards actually send important signals about how we should think about physician training. The terms “clinical experience and education,” “clinical and educational work,” and “work hours” have replaced the terms “duty hours,” “duty periods,” and “duty” to underscore that residents’ responsibility to the safe care of their patients supersedes any duty to the clock or schedule.
Reviewing The Evidence
The Task Force’s decision on clinical experience and education hours was evidence-based. The preponderance of evidence from a number of studies (cited in this letter) conducted after the current 16-hour cap was implemented in 2011 suggested that it may not have had an incremental benefit in patient safety, and that there might be significant negative impacts to the quality of physician education and professional development. To further investigate these issues, the ACGME provided seed funding and agreed to waive specific work hour requirements for two national, large, independent, multicenter trials. The iCOMPARE trial for internal medicine and the FIRST trial for general surgery were designed so that researchers can compare control groups using the 16-hour cap with test groups following more flexible work hour requirements.
While the iCOMPARE trial is still underway, the findings from the FIRST trial were published in February 2016 in The New England Journal of Medicine. This first-ever national randomized trial comparing the 16-work hour requirements with more flexible policies “demonstrated that allowing for some flexibility in the 16-hour limit did not worsen patient outcomes among general surgical patients and did not adversely affect overall resident well-being. Rather, residents in the flexible arm of the study noted several benefits with respect to patient care, continuity of care, and resident training.” A subsequent follow-up survey of FIRST trial residents published in the Journal of American Surgeons found “they strongly prefer work hour policies that allow them the flexibility to work longer when needed to provide patient care over standard, more restrictive work schedules.”
The question of work hour standards appropriately provokes great emotion in the graduate medical education community. For its part, the ACGME is committed to a learning environment that serves the best interests of both patients and residents, and we will pursue that commitment with open-minded, evidence-based policy making. The ACGME’s oversight of the professional preparation of the next generation of physicians to care for the American public requires nothing less as we set standards to support programs, residents, and faculty members as they strive for excellence in clinical care, while simultaneously ensuring ethical, humane residency education.
The final standards voted on by the ACGME Board will be shared with the graduate medical education community with implementation targeted for the 2017-2018 academic year.