Family Medicine Leaders Urge ACGME to Resist Call for More Limits on Residents' Duty Hours

The AAFP, along with the other academic family medicine organizations, have asked the Accreditation Council for Graduate Medical Education, or ACGME, to resist putting additional restrictions on residents' duty hours because such restrictions may harm family medicine training programs and the quality of patient care.

In testimony delivered during the ACGME National Congress on Duty Hours and the Learning Environment, held June 11-12 in Chicago, AAFP President Ted Epperly, M.D., of Boise, Idaho, recommended that the ACGME

The testimony from Epperly -- who also is program director and CEO of the Family Medicine Residency of Idaho -- and others came in response to recommendations contained in a report released by the Institute of Medicine, or IOM, in December 2008. In the report, the IOM recommended that continuous on-site duty periods for residents not exceed 16 hours unless a five-hour uninterrupted sleep period is provided between 10 p.m. and 8 a.m.

Other recommendations in the IOM report, "Resident Duty Hours: Enhancing Sleep, Supervision and Safety," proposed reducing residents' workloads and increasing the number of days they would have off each month.

The IOM estimated that the cost of shifting resident work to other clinicians to comply with the proposed changes would be $1.7 billion a year. A later report from the nonprofit research organization RAND Corp. and the University of California, Los Angeles, estimated those costs at $1.6 billion a year.

In his testimony, Epperly noted that family medicine has lost more than 5 percent of its residency programs in the past 10 years because of "perceived fiscal insolvency," a situation that has only worsened during the nation's recent economic downturn. Additional pressures, he said, could lead to more closings.

"The impact of additional resident duty-hour restrictions -- which, effectively, are an unfunded mandate -- could certainly accelerate the loss of family medicine residencies," Epperly said.

He explained that according to a recent survey by the Association of Family Medicine Residency Directors, or AFMRD, two-thirds of family medicine training programs could not implement new restrictions without additional financial resources, and one-fourth of them indicate that attempting to do so would result in their closing.

Moreover, said Epperly, in addition to putting greater financial pressures on residencies, the additional duty-hours restrictions could hurt the quality of education of the residents.

"We all recognize that young physicians do not learn the practice of medicine in the lecture hall. Our most robust teacher is experience with patients. Any reduction in the amount of time spent with patients is a direct loss of the experience that our residents need to learn the content and the context of health care delivery," Epperly testified.

Also testifying at the ACGME congress was Marjorie Bowman, M.D., M.P.A., of Philadelphia, professor and chair of the University of Pennsylvania Department of Family Medicine and Community Health. In her testimony, Bowman, who also is a member of the IOM, a former ACGME member, past president of the American Board of Family Medicine and past president of the Society of Teachers of Family Medicine, or STFM, focused on patient safety and continuity of care.

She said preventable hospital deaths have not declined since the most recent work-hours restrictions were implemented. That's because shorter resident duty-hour periods result in more patient hand-offs, which, in turn, affects continuity of care, Bowman said.

"Although there is little evidence that duty-hour restrictions have had any impact on patient care or safety, there is good evidence that continuity of care improves both," she said.

Bowman recommended that the ACGME study the effects of more frequent hand-offs on patient safety and the effect of duty-hours regulations in various training environments. Intensity of work varies by setting, she said, and can determine the potential impact on both residents and patients.

She also recommended that the ACGME revise its core competencies "to focus on patient safety as a system property, rather than disproportionately emphasizing duty hours." Finally, she urged committee members to distinguish between occasional, technical duty-hour violations and "a pattern of consistent resident exploitation through excessive work-hours scheduling and demands."

Signing on to the testimony of Epperly and Bowman were the Association of Departments of Family Medicine, AFMRD and STFM.

Just days after the two family physicians testified before the ACGME, the issue of resident work hours was taken up during the 2009 annual meeting of the AMA House of Delegates in Chicago, with delegates directing the AMA Council on Medical Education to study and report on the issue at the AMA's 2009 interim meeting in November.