ACGME Duty Hours Congress ACGME Duty Hours Congress PresentationPresentation

Stephen Black-Schaffer, MD, Chair, APC/PRODSStephen Black-Schaffer, MD, Chair, APC/PRODS

Association of Pathology Chairs / Association of Pathology Chairs / Pathology Residency Program Pathology Residency Program

Directors SectionDirectors Section9650 Rockville Pike, Bethesda, MD 20814-3993 Telephone: (301) 634-7880 Fax: (301) 634-7990Email: apc@asip.org Web: www.apcprods.org

What is APC/PRODS?

• APC = the Association of Pathology Chairs – chairs of 145 LCME-accredited departments of pathology in the US, Canada and Puerto Rico

• In addition to the chairs, the APC has several Sections, of which the first, largest, and most active is PRODS

• APC/PRODS = the PROgram Directors Section of the APC – the residency program directors (PDs) of 150 ACGME-accredited pathology departments

Introduction

• Pathology residencies do have a non-zero incidence of duty hour violations, as above

• However, our greatest frustration has been the poor fit between the intention of these rules and the nature of the rotations in pathology GME

• We believe our best contribution, therefore, is to start a dialogue on a useful taxonomy for GME

• We consider agreement upon a practical and effective taxonomy for GME to be a prerequisite for any effective discourse and decision making

ACGME rule Every-third-night Thirty-hours One-day-in-seven Eighty-hours Ten-hours

Violation rate 0.2% 0.5% 1.4% 1.5% 5.8%

When reasonable people disagree

• They may be talking at cross purposes

• And, if the terms they are using are neither standardized nor precise, this is quite likely

• This is certainly the case with GME duty hours

• So, what to do?

• The IOM Report pays something more than lip service to the idea that the training in GME is various, so a single set of rules may not fit

• But the areas of difference to which it points (specialty and year of training) are not useful

Finding useful parameters of GME

• Let us consider which pair of rotations has the most structural similarity:

• A medicine consult service rotation and a surgery consult service rotation

• A medicine consult service rotation and a medicine ward (inpatient) service rotation

• Structurally, the medicine consult / surgery consult gap is narrower than the medicine consult / medicine ward service chasm

• Maybe there is something about consult rotations and ward rotations worth noting…

Role of the rotation in GME

• The quotidian building block of training in GME is the rotation, and it is upon the characteristics of rotations that any taxonomy of GME must therefore be constructed, if it is to be useful

• We propose a taxonomy based on three general parameters of clinical training:

• ORGANIZATION OF CARE• SUPERVISION OF CARE• PATIENT PROXIMITY

• There are many other imaginable ways to do this – but something like it needs to be done!

Organization of clinical training• Time-based

• Shifts for continuous care (ward services, interval note)

• Sessions for periodic care (clinic services, episode note)

• Case-basedConsultative care (case eval/invest, diagnost/therapeutic note)

Procedural services (procedure prep/perform, descript/op rept)

• Project-based• Lab investigation (scientific presentation / publication)• Clinical investigation (clinical presentation / publication)

with in house call ↔ worst case scenario

home call – no shifts ↔ not worst case scenario

no call – no shifts ↔ no duty hours?

Supervision of clinical training (GME-specific)

• Real-time – presence: supervisor actually present ("over the shoulder" supervision)

• Off-line – prospective: supervisor available but not always present – involved before any diagnostic / therapeutic intervention

• Off-line – retrospective: supervisor available but not always present – not necessarily involved before every diagnostic / therapeutic intervention

• These represent a range of supervision specific to GME, out of the spectrum from UME to CME

Modes of learning in medical training (not GME-specific)

• Didactic learning of fundamentals and Independent acquisition of experience• These modes of learning place highest stress on the

individual and are of high societal stakes – a narrowly circumscribed amount of time can usefully / safely be spent on these in any day or week

• Supervised acquisition of experience• This mode of learning is less stressful for the

individual, and lower stakes for society – still of some (though diminished) benefit over greater amounts of time spent in any day or week

• This mode is most characteristic of GME

Patient proximity in clinical training

• Patient contact – real-time: primary evaluation & management / procedural service provision (clinical / operative note)

• Info processing – off-line: clinical information, chart, & image review / specimen processing (clinical consultation / ancillary service report)

What good might this taxonomy do?

• These parametric variations are specific neither to specialties, nor to particular years of training

• Virtually all specialties have some rotations that partake of most or all of these varieties of GME

• Thus, they potentially offer a tool box that the ACGME might usefully provide to all RRCs

• How might this help the RRCs?

• This might (examples follow):• Reveal opportunities for agreement• Constructively focus disagreements

Reveal opportunities for agreement► The "10-hour" rule ◄

• This taxonomy makes clear that there are case-based (consultative / procedural) rotations

• that do not involve "shifts" of continuous clinical coverage (the concept implicit in the use of the term "shift")

• The "10-hour" rule may make sense on time-based rotations involving "shifts" of continuous coverage,

• but the balance between resident fatigue and learning opportunity may be different on case-based (consultative / procedural) rotations

► The "10-hour" rule ◄

• Opportunity for agreement:• Perhaps for case-based rotations,

the corresponding rule ought to be:• 10-hours off, • averaged over a week, • with an 8-hour daily minimum,

• so as to offer a more flexible balance between resident opportunities for education and for rest

Constructively focus disagreement ► The "30-hour" and "80-hour" rules ◄

• Understanding disagreement over these rules:• Observation: duty hours peak during early

GME, corresponding to the period of peak supervised clinical experience,

• while the modes of learning in medical training at their trough during early GME are didactic learning and independent clinical experience

• Hypothesis: perhaps educators who find these long hours more acceptable are basing this on the distinction among these different modes of learning

30&80 hour rules: model "modes-of-learning" hypothesis

• Place arbitrary (illustrative) numbers on these parameters:

• high stress / stakes 50 hours per week max• didactic learning / independent experience

• lower stress/ stakes 100 hours per week max• supervised experience

• fraction of time in supervised experience:

Medical school -

pre-clinical

Medical school - clinical

Residency - early

Residency - middle

Residency - late Fellowship Practice

0% 20% 60% 40% 20% 10% 0%

30&80 hour rules: "modes-of-learning" weekly hours prediction

0

10

20

30

40

50

60

70

80

Medicalschool -

pre-clinical

Medicalschool -clinical

Residency- early

Residency- middle

Residency- late

Fellowship Practice

Didactic learning of fundamentals Supervised acquisition of experience

Independent acquisition of experience

The bulge in the python is supervised experience

30&80 hour rules: constructive focus of disagreement – on supervision

• Duty hours based on such a distinction among modes of learning plausibly approximate duty hour distributions described in the IOM report

• Actual concerns expressed by experienced PDs whose programs have very long duty hours also approximate these distinctions

• Suggests any constructive approach to change will need to be built on validation and assurance of supervision just as much as (and potentially in exchange with) amelioration of duty hours

Conclusion

• We hope we have shown both the need for and the promise of a systematic taxonomy of GME

• To be practical and effective, such a taxonomy should be rotation-based, independent of both specialty and year of training

• We believe the parameters we have illustrated are promising candidates

• We look forward to working with all parties on the development and application of such a taxonomy for the improvement of GME