ACGME Duty Hours

New ACGME Work Hour Regulations 2011

• To view the new proposed guidelines (which will take effect July 1, 2011) you can visit the ACGME website
• Some recent discussion on concerns with the new duty hours is written in a GME e-letter from the AMA. Here is the link. http://www.ama-assn.org/ama1/pub/upload/mm/40/gme-03-2011.pdf
  • Check out the editorial by Dr. Rockey (the link is on the website above). It is an article in the Mayo Clinic Proceedings that discusses the duty hours. It doesn't really specifically address some of the questions we had but discusses duty hours in general. You may find it interesting.

• The Pathology RC committee will meet April 6. They are currently putting together a list to try to appeal a few things to the ACGME. They are trying to make the ACGME understand that pathology is very different from other specialties in terms of call and the ease of using a "night float" system, which would be essentially worthless in our specialty.

Levels of Supervision

• VI.D.3. Levels of Supervision. To ensure oversight of resident supervision and graded authority and responsibility, the program must use the following classification of supervision:
  • VI.D.3.a) Direct Supervision – the supervising physician is physically
  • present with the resident and patient.
  • VI.D.3.b) Indirect Supervision:
    • VI.D.3.b).(1) with direct supervision immediately available – the supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide Direct Supervision.
    • VI.D.3.b).(2) with direct supervision available – the supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide Direct Supervision.
• Specialty specifics definitions have been posted on the ACGME website that define levels of supervision. Pathology, both residency and specialized fellowships requirements are listed on page 27-33 of this document.
  • http://www.acgme.org/acwebsite/dutyhours/Specialty-specific_DH_Definitions.pdf
  • The following is from this document...
  • Each PGY-1 resident must be directly supervised during performance of at least 3 initial procedures in each
    • Autopsies
    • Gross dissection of each surg path specimen by organ system
    • Frozen sections
    • Apheresis
    • FNA and interpretation
  • A PGY-3 or PGY-4 resident, pathology assistant or attending may supervise gross dissection of surg path specimens and/or autopsies
  • Blood bank fellows, PGY-3 or PGY-4 residents or attending may directly supervise apheresis
  • Note, as it is currently written, PGY-2 cannot supervise PGY-1 for their 1st 3 initial procedures!!!
  • However, the RC committee is rewriting this. Because, for example, a CP only PGY-2 is in essence an upper level. So this may be changing to allow for more leeway on supervision.

Duty Hours

• VI.G.4.a) Duty periods of PGY-1 residents must not exceed 16 hours in duration.
• Can first years even take home call? See controversy below under home call...
• Assuming they can... the main issue with this rule is that presently there is no exception made for our specialty who takes home call. So essentially it would be up to individual programs to decide how to make this rule work for them. If a first year resident is on call they will not be able to come back in the hospital if needed at night if they have exceeded their hours. Some options are have 1^st years come in at noon and stay till 4 am, or the first years won’t take call at all. Problem with 1^st years not taking call is that they wouldn’t be exposed to various call situations, especially on CP call or in programs with busy apheresis services. It would back up call onto 3^rd and 4^th years. ACGME reference committee for pathology is looking to petition to counter this amendment for the specialty of pathology, however earliest ruling would be in February and the latest would be April, but wouldn’t be finalized till June

Home Call

• UPDATE: After speaking with a member of the ACGME committee, first years cannot take home call. See below for possible solutions, albeit not perfect, to the problem.
• Just to be clear, home call does NOT count towards duty hours unless you have to come in to the hospital.
• Another thing to note is if you do have to come in on home call, this does NOT initiate a new minimum time off between duty periods. (The minimum for "intermediate" levels aka PGY-2 is 8 hours).
• Our associate program director is telling us that 1rst year residents cannot be on call starting the 2011/2012 academic year. If you will go to the ACGME website www.acgme.org and click on Duty Hours in the left hand column and then click on FAQs (which is the third section under new ACGME rules for July 2011), look at the bottom of page 7 and the top of page 8, It says: Question: Can PGY-1 residents take at-home call, and if so what are the work-hour restrictions for this? Duty Hour FAQs 7 Answer: PGY-1 residents are limited to a 16-hour shift and are not allowed to take at-home call. To my understanding many pathology programs are not making any changes concerning 1rst year residents taking home call (of coarse always under supervision). Are other pathology programs following this?
  • New updated response: No they can't.
  • And my program is following this (see below for possible solutions).

Solutions?

• Wish there were easy ones... I guess we gotta prepare for the worst...
• Our program is still in the planning stages but here are some ideas that were tossed around.
• For CP call assuming first years can't take home call
  • Have first years come in late... say noon... and take their 16 hours of call so they get some exposure. Or have them take evening call until their 16 hours are up. Then have a backup upper level finish the night. Downside is you got 2 people on call.
  • Backload call for upper levels and don't let first years take CP call.
    • Our program is entertaining the idea of not putting first years on CP at all, or just on maybe micro or heme. We probably will not put them on blood bank or chemistry rotations because of the "supervision" problem with them fielding phone calls.
    • Downside is upper levels get the brunt of it, but even worse first years don't get the chance to deal with call. This is especially bad if somebody is CP only...
• For CP IF first years CAN take home call (which doesn't look promising)
  • Have them take the home call, but arrange a backup upper level if they have exceeded their 16 hours and have to come in for an apheresis, etc. They can still answer the CP call pager as long as they don't have to go in to the hospital.
• AP rotations (autopsy, surg path)
  • Our program basically is not going to change much we do with this, except that first years can't take frozen call past a certain hour.
  • Basically the way you can deal with this is to include weekends in the description of rotation duties. We are going to just change the rotation to last from Monday through Saturday for half the residents and Sunday through Friday for the other half. Now not everyone will have to come in Saturday or Sunday- probably just one person. But in that way no first year is taking "weekend call." And this is legit for first years to do, as long as they 1) don't go over their 16 hours per day 2) get the next weekend off and nobody violates the one day off per seven (AVERAGED over 4 weeks). Same goes for upper levels with regards to the 1 day off per 7.
  • We will also specify that part of the surg path rotation extends until 9 at night (or whatever the cutoff for first years 16 hours is). They can be called for frozen till then. After that faculty or an upper level backup will take the calls.
  • In this way, a first year doesn't necessarily have to be in house on weekends or evenings waiting for an autopsy or frozen, but at the same time it isn't "home call" because it is part of the rotation responsibility.

Comment

Our associate program director is telling us that 1rst year residents cannot be on call starting the 2011/2012 academic year. If you will go to the ACGME website www.acgme.org and click on Duty Hours in the left hand column and then click on FAQs (which is the third section under new ACGME rules for July 2011), look at the bottom of page 7 and the top of page 8, It says: Question: Can PGY-1 residents take at-home call, and if so what are the work-hour restrictions for this? Duty Hour FAQs 7 Answer: PGY-1 residents are limited to a 16-hour shift and are not allowed to take at-home call. To my understanding many pathology programs are not making any changes concerning 1rst year residents taking home call (of course always under supervision).