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24/10/80 hour rules of ACGME

Ian Civil trauma-list@trauma.org
Fri, 14 Jun 2002 22:11:06 +1200

Dear Ken,

The issues are complex and you have delineated almost all of them.

NZ has had strict "safe hours" rules for some time and it has resulted in many of
the consequences that you have outlined. These have been driven at resident level
by unions (we have one for junior staff  (RMOs) often equating doctors with
pilots. For senior staff they are becoming driven by the courts after a couple of
well publicised cases where doctors have been found guilty of bad judgement with
length of time on duty (which most of us would regard as routine) as a
contributing cause. The employers have therefore been joined in the suits and
have been amenable to changing call hours. (Our anaesthesiologists no longer have
24 hour call for example, and if they have to work from 11pm to 8am they have the
next morning off)

Our rules for junior staff are no more than 16 hours on duty (i.e. awake in the
hospital) in one stretch and no more than 72 hours per week. This has resulted in
reduced experience, longer training time, and the need for markedly increased
number of RMOs (60 up to 115 surgical registrars in Auckland over the last 8
years. Of course in our environment the RMOs often earn more than the attending
staff (taking overtime into account) so many of these factors are not seen as
negative by RMOs. Of course the senior staff are now looking very closely at
whether as many RMOs are really needed, particularly as the increased numbers
mean decreased quality. This would require changed work practices for senior
staff who largely regard themselves as "consultants" and have been working in
that paradigm for their practicing lifetime.

Few "right" answers, lots of challenges.

We need to ensure those involved in training and service provision in surgery are
aware of worldwide trends and approaches to the issues which is where trauma.org
has huge relevance.

Whats the UK view? What about Europe? What happens in Asia, or South America.


Ian Civil

KMATTOX@aol.com wrote:

> Yesterday the ACGME issued its 24/10/80 hour rule for residents to take
> effect on July 2003.   I went to our last RRC review and to the hospital FTE
> assignments relating to both surgical house staff and faculty presence.  I
> then went to the last ACS COT VRC review for trauma centers.   The arithmetic
> Rubric cube of assignments and regulations make these many and varying
> "rules" absolutely IMPOSSIBLE to accomplish.   IMPOSSIBLE.   I spent the
> evening last night trying to work out some sort of schedule where we would:
>        1.   Get the work done
>        2.   Within an 80 hour week
>        3.   Allowing a maximum of 24 hours on duty at any one stretch
>        4.   10 hours off at the end of any work schedule
>        5.   PGY 4 or 5 response within 15 minutes of arrival of any major
> trauma patient
>        6.   Surgical faculty present for all major and significant portions
> of surgical cases
>        7.   Minimal numbers of requirements for surgery residents applying
> for their boards
> My department and hospital has "cut back" FTE resident positions in order to
> provide greater "educational" opportunities at the private hospitals, and
> because of budgetary cutbacks relating to constrained "schedule of benefits"
> as defined by HMO & RVU thinking administrators.   The public have spoken
> over the past 3 years and have stated repeatedly that they are fed up this
> this kind of health care financing and denial of access.
> I tried and tried and several things became obvious:
> 1.    It is now going to take at least 7 years for me to have surgical
> trainees exposed to the same degree of education and pathology and judgement
> making as it took 5 years ago.
> 2.    There is no way I can cover the many shifts in the hospital with the
> current allocation of staff and surgical residents without at least a 50-75%
> INCREASE in bodies and I have already been told there will be NO INCREASE,
> and expect a decrease.   By my calculations, with the new requirements and
> the current staffing numbers, we will be able to cover 3 and maybe 4 nights
> per 7 days if our clinic, elective, outpatient, and operating room
> responsibilites also remain level.  If anything, out elective and non trauma
> cases are increasing.   Therefore, we can be available to the community only
> 57-63% of the time we are currently available.
> 3.    Should we add years to the training program (beyond the 5 years), do we
> pay the residents at a PGY 6 and PGY 7 level and just how far do we slip the
> time when residents in the United States begin to operate.
> 4.    I have just reread the ACS COT VRC reports of our last two site visits
> and reread the yellow book.   I have a prediction.   Most hospitals like
> Grady, Ben Taub General Hospital, LAC, Parkland, Charity, etc. will be OUT OF
> THE TRAUMA business in 1-3 years.  We simply cannot afford to jump through
> all of the JCAHO hoops and still take care of the other patients.   I am
> aware of several hospitals in the country where neurosurgeons and even
> orthopedic surgeons and even general surgeons are paid $1500.00 per 12 hour
> night call just to be on call from home, without seeing a single patient.
> Billing is then done separately and the surgeon keeps the collections.   For
> some of these programs the neurosurgeons (and even orthopedic surgeons and
> general surgeons) are coming in to operate on as few as 3 cases per month.
> This means $500,000.00 per specialist paid to be "on call" for only 36
> operative cases per year.   Something is wrong with this arithmetic.
> This is a very sad day for me.  I never thought I would see the day when
> regulatory agencies and governments would legislate morality, judgment, and
> work hours.   As I understand the Libby Zion case, it had NOTHING to do with
> work hours and fatigue, it had to do with continuity of care.  As I
> understand, the medical resident who had been on duty but a few hours
> (certainly within the new ACGME recommendations) gave a PHONE order regarding
> a patient she did not know and there was a complication to the order given on
> the phone.   This medical resident used fatigue in her defense, even though
> fatigue was not part of her lack of continuity of care.  It was a problem of
> TOO MANY cooks, TOO many practice guidelines, and too little attention to
> detail and a poor handoff.
> The regulations I read last evening from ACGME now make it impossible to do
> the quality patient care I have seen in this countries "county" hospitals for
> the past 40 years.   It is an end of an era and I do hope and pray that the
> students and residents who filed the class action suit, ACGME that published
> the regulations, and ALL organizations that have (politically) endorsed them
> recognize what they have done to graduate education, to trauma centers across
> the country, to indigent health care, and to quality.   Congratulations, you
> have accomplished a degree of federalization and control that the Clinton
> Health Care Reform (control) initiative did not accomplish, and what many
> countries which have introduced socialized federalized medical care have
> accomplished to the dissatisfaction of the patients.   You have destroyed the
> guild of medicine.    May God grant us grace to live through this and wisdom
> to develop some schema to provide quality health care to our patients.  In
> the end, it is the American patient that is the looser of this socialistic
> victory.
> k
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