ACS Views on Legislative, Regulatory, and Other Issues

Graduate Medical Education—

• Background
• Other Activity: COGME and MedPAC
• Resident Work Hours

• ACS letter to The Honorable Phil English on the Higher Education Act, 5/24/05
• Letter to The Honorable Mark McClellan, MD, PhD, 6/12/04 (Re: Comments on Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2005 Rates, Proposed Rule [CMS-1428-P]
• ACS Letter to COGME on Workforce Study, 4/30/04
• Physician Coalition Senate Letter on Higher Education Act, 4/19/04
• Physician Coalition House Letter on Higher Education Act, 4/19/04
• ACS Senate Letter on Higher Education Act, 3/30/04
• ACS House Letter on Higher Education Act, 3/30/04
• Letter to Secretary Thompson on Unused Resident Positions, 3/8/04
• Letter to David C. Leach, 8/1/02
• Letter to David C. Leach, 6/6/02

August 1, 2002

David C. Leach, MD
Executive Director
Accreditation Council for Graduate Medical Education
515 N. State Street
Suite 2000
Chicago, IL 60610

Dear Dr. Leach:

The American College of Surgeons and the surgical specialty societies listed below applaud the efforts of the Accreditation Council for Graduate Medical Education (ACGME) Work Group on Resident Duty Hours. Our organizations all believe the recommendations made by this group can help foster an optimal educational environment for physicians in training while maintaining the flexibility that is key to preserving continuity of care and patient safety.

We agree with the recommendation that all residents should be on duty in the hospital only one night out of three and that, on average, they should have one day out of seven free of all patient care obligations. However, because of the nature of surgical care and the demands of surgical training, flexibility is needed in setting limits on the total number of hours a resident can spend in the hospital. Indeed, many surgical programs found that 80-96 hours a week are needed to meet educational requirements, attain operative skills, and imbue the discipline of the profession. Consequently, it is very important to maintain the work group's recommendations that would allow sponsoring institutions and specialties to obtain exemptions from the usual 80-hour weekly duty hour limit when necessary to meet their educational requirements.

As you know, the work involved in surgical care is variable and each surgical patient has unique needs. Frequently, proper surgical care requires a considerable amount of time in the operating room, followed by scrupulous postoperative care. When continuity of care for these patients is violated or absent, such as in the "hand off" of care to someone who is not familiar with the patient, there is evidence that the opportunities for error increase. For all surgeons, whether in practice or in training, circumstances rather than regulation should determine the duration of the workday.

For those specialties in which the residency and fellowship numbers are very small—such as colon and rectal surgery, neurosurgery, pediatric surgery, and vascular surgery—the need for flexibility is especially critical. Even slight variations in the number of patients admitted to the hospital requiring the services of these specialists can affect the total number of hours residents must spend in the hospital. The number and breadth of complex procedures that each resident in these specialties must perform to be properly trained also must be taken into account in determining their duty hours.

Finally, we would note that, in many different surgical specialty and subspecialty training programs, residents who are farther along in their training take call from home and therefore are typically "on call" every night of the week and often every other weekend. These residents may handle telephone calls from their homes, and may come to the hospital to evaluate and admit patients and to participate in emergent surgery. Therefore, we believe the recommendations should clearly state that residents taking call from home may do so every night so long as the actual number of work hours falls within the range stated above and they are permitted on average one day of seven free of all patient care obligations.

Ensuring the quality of surgical care now and in the future depends on high-quality surgical training programs. In the end, it is critically important that the resident work environment be structured to enhance the educational experience, and that teaching surgeons and program directors provide the oversight and support needed to ensure that goal is met.

Sincerely,

June 6, 2002

David C. Leach, MD
Executive Director
Accreditation Council for
Graduate Medical Education
515 N State St, Ste 2000
Chicago, IL 60610

Dear Doctor Leach:

The American College of Surgeons supports the positions of the Accreditation Council on Graduate Medical Education on the following issues.

Surgical residency is first and foremost an educational experience based on direct patient care. Implicit in a surgical residency program is the principle that all patient care provided by residents must be safe and well supervised. Patients have a right to expect that their physician is healthy, alert, responsible, and responsive and in the case of surgical patients who have undergone surgical procedures, the resident should be familiar with their operative procedure and the possible complications thereof, specifically as it applies to this patient.

It is the intent of surgical education that the surgical resident is a student and/or trainee, not an employee and that in addition to imparting surgical skills, the training of the surgical resident involves continuous and constant supervision as well as a commitment to professionalism, safe and attentive patient care in a milieu of education, and continuity of care as well. To the extent that moonlighting interferes with these all-important goals, it cannot be allowed unless approved in advance by the program director.

It is important to understand that surgical work is variable and that each surgical patient has unique needs. By its very nature, surgical care requires flexibility to deal with those needs on a case- by-case basis. The time needed to properly care for a surgical patient is determined by the severity of the patient=s illness or condition and, therefore, it cannot be regulated. Continuity of care remains an essential principle for all surgeons and surgical residents. When this continuity of care is violated or absent such as in Athe hand-off@ of care to someone who is not familiar with the patient there is evidence that the opportunity for errors in the care of patients multiples.

It has been apparent for some time that the residency experience must be restructured to ensure that it has in-depth educational value. It is inappropriate for teaching hospitals to rely upon residents to perform tasks that are not directly related to either education or patient care; these demands threaten the educational system and are a principal reason for excessive work hours. It is essential that hospitals provide sufficient support personnel to perform these non-educational tasks.

It is also essential that residents be provided with appropriate faculty support and supervision, with comfortable facilities in which to rest, eat, and study, and with opportunities outside of the work environment for personal development. Teaching institutions must have a formal oversight mechanism in place to ensure that residents truly are engaged in educational activities and that they are being fully supported and adequately supervised.

The American College of Surgeons believes that limits on resident works hours must be flexible and should fall within the range of from 80 to 96 hours per week. In addition, because of the nature of surgical care and surgical training, there must be flexibility with regard to duty hours with respect to the amount of time a resident can spend within the hospital. Continuity and quality of care, the individual patient, the relationship of the resident to that patient, and the essential nature of the number of complex procedures that a resident must perform in order to be adequately trained must be a part of the formula in determining these work hours. Circumstances must be allowed to determine duty hours.

The College also believes that surgical residents must be allowed one full weekend off each month, must be on duty, in the hospital, only one night out of three, and must be permitted one day of seven free of all patient care obligations.

Quality patient care, now and in the future, is dependent on the quality of the graduate educational experience. It is critically important that the work environment be monitored, modified, and optimized to achieve this important goal. It is, however, important to realize that the surgical resident is not caring for the patient alone. That in all circumstances there is and should be back-up and supervision in which individuals with far more experience than the residents and who are directly responsible for the care of the patient and who are capable of caring for the patient if the resident is, for any circumstances, unable to continue to care for the patient. Program directors are critical in ensuring that this goal is met, and the Residency Review Committee must be empowered to discipline programs if such back up and supervision are not available.

Respectfully,

Thomas R. Russell, MD, FACS

Revised March 7, 2005

ACS Views on Legislative, Regulatory, and Other Issues

Advocacy and Health Policy