March 26, 2013
Giving residents less time on duty and more time to sleep was supposed to lead to fewer medical errors. But the latest research shows that’s not the case. What’s going on?
Since 2011, new regulations restricting the number of continuous hours first-year residents spend on-call cut the time that trainees spend at the hospital during a typical duty session from 24 hours to 16 hours. Excessively long shifts, studies showed, were leading to fatigue and stress that hampered not just the learning process, but the care these doctors provided to patients.
And there were tragic examples of the high cost of this exhausting schedule. In 1984, 18-year old Libby Zion, who was admitted to a New York City hospital with a fever and convulsions, was treated by residents who ordered opiates and restraints when she became agitated and uncooperative. Busy overseeing other patients, the residents didn’t evaluate Zion again until hours later, by which time her fever has soared to 107 degrees and she went into cardiac arrest, and died. The case highlighted the enormous pressures on doctors-in-training, and the need for reform in the way residents were taught. In 1987, a New York state commission limited the number of hours that doctors could train in the hospital to 80 each week, which was less than the 100 hour a week shifts with 36 hour “call” times that were the norm at the time. In 2003, the Accreditation Council for Graduate Medical Education followed suit with rules for all programs that mandated that trainees could work no more than 24 consecutive hours.
April 3, 2012
Major changes are coming to the nation’s medical residency programs. The Accreditation Council for Graduate Medical Education (ACGME), the nonprofit organization that evaluates and accredits more than 9,000 medical residency programs in the United States, has announced it will transform how these programs will be accredited in the years ahead.
As described in an article published in the March 15 issue of The New England Journal of Medicine (Nasca TJ et al. 2012;366:1051-1056), the ACGME’s next accreditation system (NAS) for graduate medical education is centered on six domains of clinical competency, developed in concert with the American Board of Medical Specialties. In an interview, the article’s lead author, Thomas J. Nasca, MD, chief executive officer of the ACGME in Chicago, characterized these domains as “patient care and technical skills; medical knowledge; professionalism; interpersonal communication; systems-based practices; and practice-based learning and improvement.” Dr. Nasca stated that the NAS “is the culmination of a decade’s worth of work building consensus around the competencies.”
The difference between the past accreditation system and the NAS, said Dr. Nasca, is that the new system will evaluate educational outcomes rather than just processes, and the core or essential educational outcomes will be standardized for each specialty. To distinguish between a process standard and an outcome standard, Dr. Nasca gave the following example: “There must be simulation training in induction of anesthesia” is a process standard; “The resident demonstrates effective incorporation of knowledge and skill in the administration of anesthesia” is an outcome standard.
In July 2013, seven of the 26 ACGME-accredited core specialties will implement the NAS. The seven specialties are emergency medicine, internal medicine, neurologic surgery, orthopedic surgery, pediatrics, diagnostic radiology and urology. In July 2014, the remaining specialties will apply the NAS.
Dr. Nasca detailed some of the projected benefits of the NAS. Residents will be reassured that all programs teach and evaluate the same desired outcomes, with a “more targeted evaluation of performance, and more effective formative feedback—a focus on what is essential.” The program directors will get a less intrusive ACGME, with decreased administrative burden, giving them time for more mentoring and direct education. The public will be the “ultimate beneficiary,” because it will get better-trained physicians.
“It’s not just an educational exercise,” said Dr. Nasca. “We will reassure the public of the completeness of the training and that each graduate has demonstrated the core skills required in their chosen specialty, prior to entering clinical practice in the profession.”
According to Christine Stencel, spokesperson at the Institute of Medicine (IOM), the National Academies, Washington, D.C., “The new accreditation system is consistent with recommendations of the IOM’s 2003 report Health Professions Education: A Bridge to Quality.”
When asked about the IOM’s view of the NAS, Ms. Stencel pointed to a study of the governance and financing of graduate medical education that the IOM will begin conducting in June 2012. “The committee for that study will likely take up aspects of the ACGME accreditation reported by Dr. Nasca in The New England Journal of Medicine. IOM cannot prognosticate on what this related new study will conclude and recommend and therefore must withhold any judgments.”
A comprehensive article about the ACGME’s NAS will appear in the May issue of Gastroenterology & Endoscopy News.