Commentary: Duty Hour Changes Won't Change Resident Rotations
With the latest version of duty hour restrictions from the Accreditation Council for Graduate Medical Education (ACGME), there has been much discussion about the new shortened resident shift lengths and increased supervision. However, emergency medicine residency programs have had restrictions on the number and length of shifts for the past 20 years. Even before 1990, the Residency Review Committee for Emergency Medicine (RRC-EM) determined that there should be attending supervision 24/7 in all emergency departments where EM residents were training. The new changes will actually not change resident ED rotations at all. The recent focus by the ACGME highlights, for all specialties, two of the basic tenets of emergency medicine training: Patient care is safer, and residents learn better, when shift scheduling is reasonable and when an expert in EM is always present for supervision.
Though little will change for residents in the ED regarding supervision or shift length, there is great concern that the rules will affect our consultant residents and, consequently, patient care in the ED. If there are fewer residents working fewer hours, without any change in the manner in which patients are admitted, it is feared that academic medical centers will have even longer lengths of stay for their sickest patients, those being admitted from the ED.
The new changes to the standards for resident education will affect training institutions in other areas. On rotations in other specialties, interns will no longer be allowed to work more than 14 hours in any day. Schedules for these first-year residents will turn into either 12-hour shifts or a night float system. What type of supervision each level of resident must have is still being discussed by each specialty, but there will certainly be no more interns walking the halls without a senior resident there to guide them. In addition, the shorter hours will result in an increase in the frequency of handovers, so it is imperative that education on safe handovers of patients be emphasized.
It is obvious that the public is asking for improved supervision of junior residents engaged in patient care. Patients have read the front page news stories of residents falling asleep driving home, or overtired trainees causing patient harm, and this public perception is a strong force for change, with or without clear science to help guide that change. Emergency physicians have already shown that we care about both patient safety and our residents' education; now we can serve as a model for complying with these tenets for other specialties.
Dr. Wagner is the residency director of the Synergy Medical Education Alliance/Michigan State University emergency medicine residency program. She is also a past-president of the Council of Emergency Medicine Residency Directors.