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Published 5/1/2007
Sally Chapralis

Resident education: Rule changes compel innovation

Residency programs adapt to residency work hour regulations
When the Accreditation Council for Graduate Medical Education (ACGME) established new resident work hour rules in 2003, many practicing physicians bemoaned the “softening” of the resident experience. But the ACGME saw the changes as steps to improve patient safety and to enhance the resident educational experiences.

“As someone who experienced residency before and after the rules, I support them,” says Ryan Dopirak, MD, who completed his residency and fellowship last year. “They bring more of a balance of service and education, which should be the goal of a residency.” He also notes that “every other industry that has people’s lives at risk maintains regulations for work hours.”

Bringing programs into compliance
“Our first step toward compliance was to survey residents and keep a one-month log of the hours they actually worked,” explains Michael F. Schafer, MD, chair of the department of orthopaedic surgery at the Northwestern University Feinberg School of Medicine.

“After results revealed that residents were, indeed, working more than an 80-hour week, we took several steps that brought us into compliance,” says Dr. Schafer. Northwestern established a one-month night float rotation (7:00 p.m. to 7:00 a.m.) for third-year residents, adjusted hours off per week, and changed the weekend on-call schedule. Instead of holding one of its main teaching conferences every Saturday, the program now holds it twice a month.

“We also hired two nurse practitioners to assist in the orthopaedic spine and total joint subspecialties,” adds Dr. Schafer. “They serve as ‘resident extenders’ and as intermediaries between night floats, other shifts, and professional staff.”

Measuring the impact
“It is true that when a resident has reached the maximum number of hours or finished a night float, he or she has to turn the patient over to someone else. On the other hand, the new rules allow us more time for academics and education,” says Joshua Snyder, MD, AAOS resident liaison at the Loyola University Medical Center program in Chicago.

According to a study presented at the AAOS 2006 Annual Meeting, the new work rules resulted in fewer surgical cases for residents at the PGY2 and PGY3 levels. A review of ACGME cases entry logs showed PGY2 and PGY3 residents performed a total of 954 cases during the 2002-2003 academic year (before the work rules went into effect) and 759 cases during the 2003-2004 academic year (after the work rules were implemented)—a 21.5 percent decrease in the number of cases between the two time periods. The researchers hypothesized that resident surgical experience would be concentrated in later years, which has implications for residency education.

“Older residents do benefit from more surgical and clinical cases,” says Dr. Snyder, “but I still have the same number of cases and do not feel less challenged.”

“Residents are still getting surgical experience,” agrees Dr. Schafer. “The new rules are prompting us to look at other avenues for surgical exposure including the greater use of cadavers for teaching some techniques. The Orthopaedic Learning Center provides another opportunity for learning surgical procedures, such as arthroscopy.

“Northwestern has always been and continues to be very attentive to patient safety issues—from intake to discharge at every point in the process—and we underscore patient safety throughout our resident education,” adds Dr. Schafer. “The intention of the new rules is noble and should be lauded; however, it’s all about time. Educators are busy in many venues, and changing a curriculum or academic approach takes time, but it must be done.”

“Residency programs do a great job of teaching orthopaedic medicine, and AAOS educational resources and opportunities increase our knowledge base,” says Dr. Dopirak. But now that he is in private practice, Dr. Dopirak is facing his latest challenge. “We need more practice management and business education.”

The Standards

  • The ACGME’s common duty hour standards include the following requirements:
  • An 80-hour weekly limit, averaged over four weeks
  • An adequate rest period, which should consist of 10 hours of rest between duty periods
  • A 24-hour limit on continuous duty, and up to 6 added hours for continuity of care and education
  • One day in seven free from patient care and educational obligations, averaged over four weeks
  • In-house call no more than once every three nights, averaged over four weeks