Is your doc a rookie? Rule changes would spell it out, and give medical residents fewer hours

Rookie docs may get more oversight, shorter shifts

CHICAGO — Patients will be told when they’re being treated by rookie doctors, who would get shorter shifts and better supervision under proposed work changes for medical residents.

The draft regulations aim to promote patient safety and reduce medical errors by enhancing work conditions for sometimes sleep-deprived junior physicians.

The proposal slightly revises regulations adopted seven years ago and would have the biggest impact on interns — new doctors in their first year of residency training programs in hospitals after graduating from medical school. They would be more closely supervised by experienced doctors and the maximum length of their work shifts would be cut from 24 hours to 16 hours.

Maximum work shifts would remain 24 hours for residents in their second year and beyond. Maximum work weeks would remain at 80 hours for all hospital residents.

All residents and their supervisors also would be required to explain their roles to patients and explain that supervisors are ultimately in charge of their care.

The proposal comes from the Accreditation Council for Graduate Medical Education. Dr. Thomas Nasca, the group’s CEO, said the changes are needed to meet the main goals of graduate medical education — assuring patient safety while teaching new doctors professionalism and putting patients’ needs above their own.

Residency programs, typically lasting three to seven years, give new doctors on-the-job training in patient care along with expertise in their chosen specialty. The programs often involve notoriously long hours that can lead to sleep deprivation, which research shows can contribute to medical errors.

Violations to the accrediting group’s 2003 regulations are common and some groups including the influential Institute of Medicine, have pressed for stricter regulations. The accrediting group included some but not all of the institute’s recommendations in the revision.

Dr. Sidney Wolfe of Public Citizen is among advocates who had pressed for stricter shift limits for all residents. Working 24 hours without sleep is dangerous for residents and their patients, and shortening hours for interns only “makes no sense at all,” he said.

A coalition including his group issued a report card on the draft, including an “F” on oversight because the group ignored a recommendation for government monitoring of work-hour regulations. The group proposes instead increasing its own site visits to check on compliance.

The draft rules, released Wednesday by the New England Journal of Medicine, will be available for public comment on the accrediting group’s website until Aug. 9. They also require approval from its board of directors. Changes likely won’t be implemented before July 2011.

Whitney Lyn, who will soon finish her first year in a family medicine residency program in Chicago, said the existing regulations are fine — when they are enforced — and that the proposed changes would stifle residents’ autonomy.

They would require supervising doctors to be present or nearby by when interns are treating patients — not just available by phone as sometimes occurs now.

“If you have that much supervision over an intern,” Lyn said, “they’re not able to grow as a physician and make independent decisions.”

Lyn said interns in her program get a five-hour sleep break during shifts lasting up to 30 hours, which she said is usually enough to combat fatigue. (Shifts can last longer than 24 hours to transfer care of patients to doctors on the next shift.)

She said she’s had only one lapse, probably due to sleepiness. She forgot to give a drug to a heart patient during an overnight shift — but the patient wasn’t harmed and got the medicine when another doctor reminded her in the morning.

Dr. Joanne Conroy, chief health care officer at the Association of American Medical Colleges, said her group supports the changes. She said it will be a challenge to balance revised hours for interns with continuity of care for patients, but called that proposal a good compromise.

“We understand that those residents are our most vulnerable learners,” Conroy said.

John Brockman, president of the American Medical Student Association, gave the revision a mixed review. He favors a 16-hour shift limit for all residents, but he said the emphasis on increased supervision, and informing patients about the roles of residents “absolutely will make a difference in patient care.”

Online:

Accrediting group: www.acgme.org

New England Journal: www.nejm.org