Duty Hours in Emergency Medicine: Balancing Patient Safety, Resident Wellness, and the Resident Training Experience: A Consensus Response to the 2008 Institute of Medicine Resident Duty Hours Recommendations

Abstract

Representatives of emergency medicine (EM) were asked to develop a consensus report that provided a review of the past and potential future effects of duty hour requirements for EM residency training. In addition to the restrictions made in 2003 by the Accreditation Council for Graduate Medical Education (ACGME), the potential effects of the 2008 Institute of Medicine (IOM) report on resident duty hours were postulated. The elements highlighted include patient safety, resident wellness, and the resident training experience. Many of the changes and recommendations did not affect EM as significantly as other specialties. Current training standards in EM have already emphasized patient safety by requiring continuous on-site supervision of residents. Resident fatigue has been addressed with restrictions of shift lengths and limitation of consecutive days worked. One recommendation from the IOM was a required 5-hour rest period for residents on call. Emergency department (ED) patient safety becomes an important concern with the decrease in the availability and in the patient load of a resident consultant that may result from this recommendation. Of greater concern is the already observed slower throughput time for admitted patients waiting for resident care, which will increase ED crowding and decrease patient safety in academic institutions. A balance between being overly prescriptive with duty hour restrictions and trying to improve resident wellness was recommended. Discussion is included regarding the appropriate length of EM training programs if clinical experiences were limited by new duty hour regulations. Finally, this report presents a review of the financing issues associated with any changes.

Competence and Challenges of Emergency Medicine Training as Reported by Emergency Medicine Residents

“…Emergency medicine residents have higher rates of substance use than residents in other specialties, specifically related to cocaine and marijuana (9). Experts in training in Emergency Medicine have recommended a balanced approach to duty hours to support patient safety, resident wellness, and the resident training experience, including resident education, duty hours compliance, and working with institutions and residents to find solutions to stressors and service requirements (10,11).…”

A National Survey of Academic Emergency Medicine Leaders on the Physician Workforce and Institutional Workforce and Aging Policies

“…In addition to these fields, trainees also experience shift work now with the ACGME's changes in duty hours requirements. 23,24 The results of our survey suggest that planning for and distributing the clinical workload across the workforce is critical to recruiting and retaining faculty. For example, modifying an older faculty member's off-hours clinical workload to accommodate his or her age or other factors indicates to younger physicians that the department will meet their evolving personal and professional needs in the future.…”

Education and service: how theories can help in understanding tensions

“…), and studies identifying the impact of structural and systems changes (at a national or local level) on training and patient care (e.g. ). Of the papers reporting primary research (as opposed to reviews or discussion articles), the dominant methodology was the bespoke survey, followed by descriptive qualitative inquiry …”