RSNA News - November 2004

Limits on Resident Duty Hours Have Initial Positive Impact

My concern is that the programs need to pay attention so the resident doesn't lose too much education and peer interaction.
— Carol Rumack, M.D.

Residency programs across the country are using innovative scheduling and changes in staffing to meet new duty hour standards set forth in July 2003 by the Accreditation Council for Graduate Medical Education (ACGME). The guidelines limit the number of resident duty hours in the hospital, including time spent on call, to 80 hours per week averaged over four weeks. ACGME hopes this change will protect patients and reduce resident fatigue.

This summer, ACGME reported that most teaching programs are in compliance with the standards. "The Council is gratified by the response of the teaching hospitals in the United States as they met the challenge of implementing the duty hour reforms for residents," says ACGME Executive Director David C. Leach, M.D. "Major redesign of the healthcare system is still needed and we have a long way to go before we get it right. However, much has been learned in the last year."

Effect on Radiology

While interventional radiology departments have had to deal with both the duty hour limits and the 24 + 6 rule, most diagnostic radiology departments have had to make only minor adjustments in the way they handle residency programs. "People have generally been in compliance," says Carol Rumack, M.D., chair of ACGME's Diagnostic Radiology Residency Review Committee.

When the new rules came into play, cost had been a major concern but Dr. Rumack says she hasn't heard radiology departments complain about budgetary woes as a result. "Because the workload has increased dramatically, people are having to come up with plans for call," she says. "The main impact is the increase in the number of programs using a night float system. With the new rules, residents will be on five or six nights in a row, with no daytime responsibilities, no educational responsibilities and no peer interaction when they add night float rotations to cover call. My concern is that the programs need to pay attention so the resident doesn't lose too much education and peer interaction."

The new duty hour standards require that residents work no more than 80 hours a week on average, and get a 10-hour rest period between assigned shifts. Dr. Rumack says some programs may look at moving noon lectures and conferences to an earlier or later time. That way, residents who cover the night shift can review their cases with the attending radiologist and still attend educational conferences with other residents before they have to leave the hospital to comply with ACGME standards.

Brian Steele, M.D., chief resident in the radiology program at Loyola University School of Medicine in suburban Chicago, believes faculty and physicians take work hour limits seriously. "I think they're almost hypersensitive to it. I was in the hospital on one occasion and was almost borderline late, and one of the faculty got angry with me for being there," he explains. "She was clear that I was not to be in the hospital."

Dr. Steele says Loyola's radiology department was already in compliance before the standards were put in place. "I think residents generally like the reforms," he says. "The only problem I see is when a test is ordered. I'm on at 8 p.m. and by the time the test is done and interpreted, the person who ordered it might have to leave because of duty hours. If I'm not told whom to contact with the results, I have to do extra legwork—and that can be annoying."

Dr. Steele's residency program director, Laurie Lomasney, M.D., agrees with his assessment. "We are having to make more of an effort to find the responsible referring physician," she says. "We also have to create a better method of documentation so that we know who's available and who's going home."

Third-year resident, Robert Demayo, M.D. (left), consults on a case with Robert Goodman, M.D. assistant professor of pediatric radiology at the Yale University School of Medicine.

Photo courtesy of James Brink, M.D.

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When new standards were being debated, most concerns were for smaller radiology programs that depended on residents for night coverage. Santa Barbara Cottage Hospital is a program that had to make some changes. "Our residents used to work a night float in which they'd get off at 10 a.m. and come back at 5 p.m.," explains Arthur Lee, M.D., director of the hospital's diagnostic radiology residency program. "To meet the required 10-hour rest period, we spread the late duty hours among the staff. We have a staff person stay until 8 p.m. until a resident comes. It's not that bad. It only comes up once or twice a month."

Dr. Lee says the duty hour rules have improved morale among the residents and haven't really impacted the quality or quantity of cases they get to see. "In fact, the staff in the emergency room and other departments like having an attending here at 7:30 p.m. They get more definitive readings," he says. "And that's better service."

Yale-New Haven Hospital was already in compliance before ACGME standards were instituted. It's one of a few departments featuring 24/7 radiology coverage. "We were under pressure from trauma surgeons and emergency physicians to provide a comparable level of service around the clock, so we were almost completely unaffected by the new standards," says James Brink, M.D., interim chairman of the Department of Diagnostic Radiology.

Dr. Brink says there is increasing pressure on hospitals to prove that radiology services billed were actually performed at the time of the patient's treatment. He believes that trend may again change the dynamics in radiology residency programs with more programs covering with attending physicians who can bill for nighttime services.

Dr. Brink and other faculty agree that the changes in ACGME standards highlight the balancing act residency programs must perform. They must protect patients and physicians from mistakes made due to fatigue, while giving tomorrow's medical professionals experience interpreting diagnostic tests.

"The experience of reading on your own is invaluable," says Dr. Lomasney. "That's when we have to make decisions and depend on our colleagues in the hospital. It's not isolated learning. Radiology is a consultative service and learning that method of communication is critical."

ACGME is hoping its newest standards make sure that education takes place while residents and fellows are rested and ready to learn.