Physicians Call on ACGME to Use Evidence for Creating Shift Guidelines

Two physicians from UCSF call on the medical Accreditation Council to raise the bar on how it determines physicians can be trained.

In a new commentary published by Journal of the American Medical Association (JAMA) Internal Medicine, two physicians write that the Accreditation Council for Graduate Medical Education (ACGME) “has used limited evidence to support duty hour policies.” In July of this year, that body raised the limited shift length for interns and resident clinicians from 16 hours to 24, though the 24-hour limit had already been in place for those in the second year of their residency and beyond.

Elaine C. Khoong, MD, and Anne S. Linker, MD, are both physicians in the Department of Medicine at the University of California San Francisco. The two completed their residencies in 2017, and they wrote that they “know how substantially the ACGME policies impact training and resident clinician quality of life.”

Their commentary notes positives and negatives to both 16-hour and 24-hour shifts. The evidence used by the ACGME to make their decisions, they say, has been incomplete. They wrote that the ACGME’s decision was partly based on the recent Flexibility in Duty Hour Requirement for Surgical Trainees (FIRST) trial, which randomized either the previous 16-hour limits versus flexible duty-hour policies with outcomes of 30-day postoperative death or serious complication.

The results of that trial were equivalent at the primary outcomes, with mixed results in secondary outcomes for clinicians: better educationally, worse in personal satisfaction. “These mixed results do not suggest a clear policy direction for the work hours of surgical trainees,” Khoong and Linker wrote.

“Although the use of trial evidence is encouraging, the ACGME has set the bar quite low for the quantity and quality of acceptable evidence,” the two said.

The debate at hand is a vital one for population health considerations. The two physicians argue that, although clinical training occurs over a relatively short period of time, it “has outsized influence on how trainees develop into clinicians.” The impacts will follow a physician for years of their careers, and as such will impact thousands of patients along the way.

Physician burnout is an increasingly important consideration for hospital management, impacting performance in every corner of medicine and across the spectrum of tasks expected of medical professionals. The Linker and Khoong wrote that “often interns are the physicians entering orders and performing detail-oriented tasks that are substantially impacted by attention.”

Their thought process is that perhaps a blend of staff working 16 and 24 hour shifts would be a good approach, where “at least 1 member of the team (resident clinician) stays overnight on the day of admission and another member of the team (intern) is present the entire second day...this is a sound approach that facilitates team-based patient care.”

The JAMA commentary concludes by noting the importance of evidence-based policies, and calls on the ACGME to “make greater use of evidence to guide the tradeoffs between duty hours, patient care, work-life balance, and training goals.”

Last week, the ACGME announced its intentions to do something of the kind. Their newly established Patient Safety Collaborative will incorporate 9 major medical institutions from across the country to create and test a framework "that will focus on optimizing the engagement of residents and fellows among the six Focus Areas of the ACGME’s Clinical Learning Environment Review (CLER) Program: patient safety, health care quality, care transitions, supervision, fatigue management (well-being), and professionalism."