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New ACGME Work Hour Regulations 2011Edit
- To view the new proposed guidelines (which will take effect July 1, 2011) you can visit the ACGME website
- We encourage residents and programs to read through the guidelines fully, but would like to point out several particular topics that will most impact residency programs and scheduling
- Direct supervision of first years (see below for more information)
- The new regulations on first year duty hours (see below for more information)
- 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.
Levels of SupervisionEdit
- One of the big changes in the guidelines is more strict guidelines for supervision, in particular for supervision of first year residents.
- 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.
- The following is from this document...
- Each PGY-1 resident must be directly (see definition of direct supervision below)supervised during performance of at least 3 initial procedures in each
- Gross dissection of each surg path specimen by organ system
- Frozen sections
- FNA and interpretation
- Our program is thinking about going to a "checklist" system for new first years. It is up for debate how to handle for example 2nd or 3rd years who may have already done some of these things before. Do they need a checklist also? Do we "grandfather" them in?
- An upper level resident, pathology assistant or attending may supervise gross dissection of surg path specimens and/or autopsies
- Blood bank fellows, upper level residents or attending may directly supervise apheresis
Definitions (from the ACGME Guidelines and from the Speciality-Specific Guidelines)
- Upper levels are defined as
- PGY3 or PGY4 if a resident is combined AP/CP
- PGY2 or PGY3 if a resident is AP only or CP only
- It is still unclear to me if a PGY2 AP/CP ("intermediate level") can supervise a PGY1
- 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.
- VI.G.4.a) Duty periods of PGY-1 residents must not exceed 16 hours in duration.
- PGY-1 residents should have 10 hours and must have 8 hours off between duty periods
- Yes the math is off...
- First years cannot take home call. See Solutions section below for possible solutions, albeit not perfect, to the problem.
- See the ACGME website. 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.
- Home call is allowed for PGY-2 and above
- Home call does NOT count toward total duty hours (80 per week) unless you have to come in to the hospital
- If you do come in, it does not initiate a new duty period (aka you can come in before 8 hour "time off between shift" requirement)
- Time off between duty periods
- Intermediate level residents (see below for definition) should have 10 hours free and must have 8 hours free
- Residents in final years of education (see below for definition) must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or extended periods
- This preparation must occur within the context of the 80-hour maximum duty period length, and one-day-off-inseven standards. While it is desirable that residents in final years of education have 8 hours free between periods there may be circumstances when these residents must stay on duty to care for their patients or return to the hospital with fewer than 8 hours off
- These circumstances defined by RRC committe include
- Intraop consults
- Emergent autopsies
- Immediate cytology eval
- Transfusion/blood bank emergencies
- Heme emergencies
Definitions (from the RRC Committee)
- Intermediate level residents
- PGY-2 if combined AP/CP
- Residents in final years of education
- PGY-3,4 if combined AP/CP
- PGY-2,3 if AP only or CP only
- Question: Our associate program director is telling us that 1rst year residents cannot be on call starting the 2011/2012 academic year. If you will 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?
- Though it is certainly up to programs to interpret the guidelines as they see fit, we strongly urge all programs to carefully read the guidelines to avoid any violations.
- From my understanding most programs are following them and not putting first years on call per se. See below on ways to deal with weekends etc (see 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
- Some debate is going on at our program as to whether or not first years can field calls from clinicians on CP. Is this still directly supervised if the attending doesn't hear the phone call? Up for debate I guess so each program will have to decide for themselves.
- Here are ways that have been discussed...
- Have first years come in late... say noon... and take their 16 hours of "duty" (don't call it call) so they get some exposure. Or have them come in the regular time and take evening "duty" until their 16 hours are up. Then have a backup upper level finish the night.
- Several downsides
- Upper level still has to cover the rest of the night
- If they come in late, they may miss out on protected education time, for example morning conferences
- Several downsides
- Backload call for upper levels and don't let first years take CP call. Obviously this is not ideal for either side (first years don't get experience and upper levels take on more).
- For programs with a busy pheresis service...
- Extend the work week to include weekends (similar to that described below for AP rotations). Have a first year assigned to cover pheresis on weekends until their 16 hours are up (9:00ish). Don't call this "call," just call it weekend duty. While it may not be any different from what you have been doing in the past on CP call, it is now simply not referred to as call. It is not in violation of duty hours as long as the first year doesn't exceed 16 hours and is directly supervised (see above for levels of supervision). After this certain time an upper level can take call.
- On weekdays, have the first years also cover pheresis in the evenings, not to exceed 16 hours. Again, you can't call this call. Just say that the rotation responsibilites last until 9:00 pm. And supervise them. Again, have an upper level cover after this time is up.
- For AP rotations (autopsy, surg path)
- Weekend surg path/autopsy
- Extend the rotation responsibilities to include weekends. Not everyone has to come in on weekends, just 1 person. You can't call this call, but it is essentially not very different. If this person who comes in is a first year, have them stay and gross/do autopsies for their 16 hours, and then after that have an upper level take calls. As long as the first year doesn't exceed 16 hours, is supervised according to the rules (see above section for supervision details), and it is not referred to as call, this is not in violation.
- Specify that the surg path rotation responsibilities extend 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. As far as we know this is totally legit and does not violate the rules as long as first years are not called after 16 hours.
- Weekend surg path/autopsy
Here is a list of FAQ that the Pathology RC Committee has put together which you may find helpful
- Q: The revised Common Program Requirements (effective July 1, 2011) preclude PGY-1 residents from taking call. How can Pathology Program Directors provide PGY-1 residents the educational experiences similar to what they are receiving currently during 'on call' assignments?
'A. The 'new' requirements specify the following for PGY-1 residents:
· a maximum 80-hour work week
· duty periods that must not exceed 16 hours
· a 10-hour minimum time off between duty periods (should be scheduled) and an 8-hour minimum time off between duty periods (must be scheduled)
The PGY-1 resident does not need to be 'in house' during a 16-hour duty period. The duty period may include time in the institution/hospital and time outside of the institution/hospital. Expectations are that the PGY-1 resident continues to assume clinical responsibilities assigned, and remains under obligation to the program for the defined duty hour period.
ANATOMIC PATHOLOGY '
· A PGY-1 resident on surgical pathology works from 7:00 am to 9:00 pm (14 hours) in-house grossing surgical specimens, conducting intraoperative consultations, and/or previewing cases. This resident would leave the hospital at 9:00 pm and return at 7:00 am the next morning. Another resident, fellow, or attending would be responsible/under obligation to the program for intraoperative consultations between 9:00 pm and 7:00 am the following morning. If the PGY-1 resident was scheduled from 7:00 am to 11:00 pm (16 hours), he/she could not return to work until 9:00 am the next day (10-hour rest period).
Participation in critical cases is important. However, schedules of PGY-1 residents must be organized with flexibility in mind as PGY-1 residents may not under any circumstances be assigned duty hour periods that exceed 16 hours.
· A PGY-1 resident is assigned to the surgical pathology rotation. The duty period is defined as 8:00 am to 10:00 pm. The resident, however, leaves the hospital at 6:00 pm, but remains responsible for clinical activities until 10:00 pm (14 hours). The resident must remain in communication with the laboratory, operating, room, senior resident, fellow, or supervising faculty member. If an intraoperative consultation is requested, the resident is expected to complete the remainder of the duty hour period that ends at 10:00 pm. In this case the duty period can be extended until 12 midnight to maximize the 16-hour shift. Depending on the clinical and didactic needs in the program, it is acceptable for duty hour periods to be scheduled in 16-hour shifts. Time within the duty hour period can be managed accordingly.
It is important to note, however, that once the PGY-1 sixteen-hour shift ends, another resident, fellow, or the attending pathologist will be responsible for any additional consultations. The PGY-1 resident assigned from 8:00 am to 12 midnight will be able to begin another duty period at 8:00 am the next morning, because the requirement states that residents should have 10 hours, but must have 8 hours between duty hour periods. While 10 is the preferred threshold, 8 is the minimal standard.
'CLINICAL PATHOLOGY '
· A PGY-1 resident is assigned to a blood bank/transfusion medicine rotation. The resident's responsibilities include assignments during the day hours of 8:00 am - 5:00 pm, in-house. The resident leaves the hospital/institution at 5:00 pm but is still responsible for clinical assignments until 10:00 pm. The resident maintains communication with the laboratory, a more senior resident, or a supervising faculty member during the latter 5-hour period. He or she responds to inquiries from the blood bank or from providers. If the resident leaves the hospital for self-study, rest or relaxation, or any other reason approved by the program director, he/she is expected to return to the hospital if needed to complete his/her 16 hour duty period (example: to perform an apheresis procedure).
If a 'critical' patient encounter extends beyond 10:00 pm, (as defined in the specialty-specific language in the requirements - VI.G.5.c.1.) the PGY-1 resident may complete the care of the patient, but then must be released. Another resident, fellow, or supervising attending will assume responsibilities for any additional patient procedures. The PGY-1 resident assigned from 8:00 am through 10:00 pm will be able to return to the hospital and begin a duty period at 8:00 am the next morning.
''REDEFINING' Rotations '
· A PGY-1 resident is assigned to an autopsy rotation. The responsibility/obligation of the resident includes: 1) providing expertise for performing autopsies, 2) chart review, 3) review of gross organs, 4) dissection, 5) consultation with referring physicians, 6) slide review, and 7) generation of both PAD and FAD reports daily, Monday - Saturday. Example duty periods during these days: Monday through Friday 8:00 am - 5:00 pm and Saturday, 8:00 am to 3:00 pm. The resident would not have responsibilities/obligations on Sunday in order to meet the 'one-day-in-seven off' duty hour requirement.
· Similarly, a PGY-1 resident is assigned to a surgical pathology rotation. The responsibility/obligation of the resident on this service could include assignments Monday through Saturday or Sunday through Friday (example: 8:00 am to 8:00 pm Monday-Friday; 8:00 am to 3:00 pm Saturday and /or Sunday)
'Q: For residents enrolled in 3-year Pathology tracks (Clinical Pathology, Anatomic Pathology), or Anatomic Pathology/Neuropathology what level residents are considered to be in their final years of education? '
A: PGY-2 and PGY-3 level residents in 3-year programs are considered to be in their final years of education and PGY-2 level residents in AP/NP are considered to be in their final years of education.
'Q: Who are qualified to supervise residents in bone marrow biopsies? '
A: PGY-2 or greater level residents in a CP-only track, PGY-3 or greater level resident in an AP/CP track, hemeonc fellows, hematopathology fellows and attending pathologists may supervise the performance of bone marrow biopsies.
'Q: Who are qualified to supervise residents in apheresis procedures? '
A: PGY-2 or greater level residents in a CP-only track, PGY-3 or greater level residents in an AP/CP track, Blood Banking/Transfusion Medicine fellows, and attending pathologists. Hematopathology fellows may also supervise apheresis procedures if approved to do so by their respective program directors.
'Q: Who are qualified to supervise residents in gross dissection of surgical path specimens and/or autopsies? '
A: A PGY-2 or greater level resident in an AP/NP or AP-only track, a PGY-3 or -4 level resident, a fellow, a pathology assistant, or an attending pathologist.
'Q: At what point may the PGY-1 resident be indirectly supervised? '
'A: In order for the PGY-1 resident to be indirectly supervised, they must have performed the requisite three procedures in the categories specified in the requirements. [VI.D.5.a.(1) - autopsies (complete or limited), gross dissection of surgical pathology specimens by organ system, frozen sections, apheresis, fine needle aspirations and interpretation of the aspirate.]
Example: The resident who has met the requirement for direct supervision may be indirectly supervised by a more senior resident, a fellow, a pathology assistant, or an attending physician. The identified supervisor must be available for consultation and assistance, but does not need to be immediately available or in the hospital.
There is a thread discussing the new ACGME rules on studentdoctor.net: http://forums.studentdoctor.net/showthread.php?t=798802