Community Conversation (Duty Hours) 12/10
We overviewed the new duty hour rules that are to be implemented in July, 2011.
See www.acgme.org for more information.
Briefly, they include:
Residents can work a maximum of 80 hours per week; They must have 1 day off per week on average; Interns can work a maximum of 16 continuous hours; Upper level residents can work a maximum of 24+4 hours; A Strategic Nap is encouraged; There must be a minimum of 10 hours off between duty periods; and Residents can work no more than 6 nights in a row of night float.
Questions to frame our discussion included:
- Are we preparing students for internship or for doctoring?
- How should clerkship students and AI’s be treated differently?
- How should this affect early clinical exposure and framing?
Various thoughts were outlined and discussed by Academy Members:
- Many faculty worry about continuity for patients. We need to have students understand continuity as a positive experience. We need to emphasis the importance of continuity for patients and continuity with teachers. Continuity is being lost in our attempts to meet work hour demands.
- We need a core group of teachers to know and spend time with the students.
- The hospital should support a small group of teachers on the clinical services.
- Students complain about attending changing very frequently. They have counted on residents to continue to be present. This will challenge that.
- Frequent changes challenge students because students worry as much about pleasing their evaluators as actually learning content.
- Students need someone to know them. Resident changeovers will make student interactions with their supervisors even more disjointed making clinical evaluations even more problematic.
- Students will struggle in the transition from years one and two to year three as they go from excellent continuity of teaching to disjointed teaching relationships. It is very different.
- We need to use the models from the longitudinal experience in Asheville to help us.
- We need to have rvu’s for teaching to reward educators.
- There is a dilemma in apprenticeship model teaching versus having all students have the same experience. LCME standards force us to assure that all students see and do the same things. However, we prefer to teach through an apprenticeship model which allows for stronger individual relationships. We cannot do both at the same time well.
- This is an opportunity to train medical students better. Graduates several years from now should be better at sign out/ hand offs than current interns. Despite the fact that we have been able to see this coming, today’s graduates are no better than graduates several years ago. We have to change how and what we teach to accommodate this new important skill, and others that are similarly needed in today’s work environment. We need to begin that teaching early, in years one and two. Just as students in ICM learn how to present an H&P they need to learn how to sign out. They also need early exposure to working with non-physicians on clinical teams.
- This is an opportunity to focus on developing an AI curriculum with more purpose than simply getting letter of recommendation. Some national groups are working on how to prepare students for residency. We could be more purposeful in our setting by developing more courses specifically targeted toward preparation for internship. We need to help them be ready to take care of patients as interns.
- We should take this opportunity to allow the students to help more, the students can be the continuity for patients and therefore be more valuable in the clinical environment. We should allow students to work longer, not just like interns, for this purpose.
- Regarding students we should not make rules we don’t have to about work hours. We should focus on our educational goals and not compliance with unwritten rules.
- In a current night float system that peds tried in anticipation of the work hour change (at WakeMed) the better students seem to shine even more as they really help with continuity for patients.
- Many physician extenders are doing a lot of the teaching because of the fact that they are now often the ones doing the direct patient care. Is that ok? There are pluses and minuses to this. Some are great teachers but shouldn’t physicians be teaching physicians?