Clinical Fellow, Hematology and Oncology, Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center
This academic year stands as a landmark in residency training in the United States as the Accreditation Council for Graduate Medical Education (ACGME) announced new standards for resident duty hours and for the learning and working environment (Table). The effects of these new standards influence the day-to-day practice of subspecialty services. Hematology services in teaching hospitals rely on internal medicine (IM) residents for patient care and were required to assent to these new standards, which necessitated modification of hematology training program rotations and inpatient services.
The new duty-hour standards aim to create a structure that allows residents to gradually develop their skills, knowledge, and attitudes as independent clinicians. Program directors are encouraged to design a graded and progressive training plan with proper supervision; this concept of graded and progressive responsibility is one of the core tenets of the ACGME. As a result, IM residency program directors were instructed to decrease the workload of the postgraduate year 1 (PGY1) residents and increase the clinical responsibilities of PGY2 and PGY3 residents (Table). The precise adjustments depend on the service and program. Some services hire moonlighters to cover work previously done by PGY1 residents while other programs create mixed resident teams with a variety of combinations of PGY1, PGY2, and PGY3 residents. On the medicine service, the classical structure of attending physician, resident (PGY2 or 3), and intern (PGY1) is usually maintained, but the structure in some of the subspecialty services has had to be changed.
Table. Resident Duty Hours Comparison of 2003 and 2011 Standards. From the Accreditation Council for Graduate Medical Education (ACGME).
| . | 2003 Standards . | 2011 Standards . |
|---|---|---|
| Maximum hours of work per week | Duty hours are limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities. | Duty hours are limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities and all moonlighting. |
| Mandatory time free of duty | Residents must be provided with one day in seven free of duty every week. | Unchanged |
| Maximum duty period length | Continuous on-site duty, including in-house call, must not exceed 24-consecutive hours. Residents may remain on duty for up to six additional hours if needed. | Duty periods of PGY1 residents must not exceed 16 hours in duration.Duty periods of PGY2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital. Strategic napping is strongly suggested. Residents may be allowed to remain on site no longer than an additional four hours. |
| Minimum time off between scheduled duty periods | Adequate time for rest and personal activities must be provided. This should consist of a 10-hour time period provided between all daily duty periods and after in-house call. | Residents should have 10 hours, and must have eight hours, free of duty between scheduled duty periods. Intermediate-level residents must have at least 14 hours free of duty after 24 hours of in-house duty. |
| Night float | Residents must not be scheduled for more than six consecutive nights of night float. | |
| Maximum in-house on-call frequency | In-house call must occur no more frequently than every third night, averaged over a four-week period. | PGY2 residents and higher must be scheduled for in-house call no more frequently than every third night |
| Patient care responsibility | PGY1 residents must not be responsible for the ongoing care of more than 10 patients.When supervising PGY1 residents, the supervising resident must not be responsible for the ongoing care of more than 14 patients.When supervising more than one first-year resident, the supervising resident must not be responsible for the ongoing care of more than 20 patients. |
| . | 2003 Standards . | 2011 Standards . |
|---|---|---|
| Maximum hours of work per week | Duty hours are limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities. | Duty hours are limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities and all moonlighting. |
| Mandatory time free of duty | Residents must be provided with one day in seven free of duty every week. | Unchanged |
| Maximum duty period length | Continuous on-site duty, including in-house call, must not exceed 24-consecutive hours. Residents may remain on duty for up to six additional hours if needed. | Duty periods of PGY1 residents must not exceed 16 hours in duration.Duty periods of PGY2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital. Strategic napping is strongly suggested. Residents may be allowed to remain on site no longer than an additional four hours. |
| Minimum time off between scheduled duty periods | Adequate time for rest and personal activities must be provided. This should consist of a 10-hour time period provided between all daily duty periods and after in-house call. | Residents should have 10 hours, and must have eight hours, free of duty between scheduled duty periods. Intermediate-level residents must have at least 14 hours free of duty after 24 hours of in-house duty. |
| Night float | Residents must not be scheduled for more than six consecutive nights of night float. | |
| Maximum in-house on-call frequency | In-house call must occur no more frequently than every third night, averaged over a four-week period. | PGY2 residents and higher must be scheduled for in-house call no more frequently than every third night |
| Patient care responsibility | PGY1 residents must not be responsible for the ongoing care of more than 10 patients.When supervising PGY1 residents, the supervising resident must not be responsible for the ongoing care of more than 14 patients.When supervising more than one first-year resident, the supervising resident must not be responsible for the ongoing care of more than 20 patients. |
An additional core concept is to ensure that the development of skills is achieved in a safe and effective environment for both the patients and residents. As a result, ACGME mandated a cap on the number of patients who are treated by the residents according to the level of training (Table). In some cases, IM program directors made an independent decision to decrease the recommended cap based on the complexity of the patients on the teaching service and the availability of the residents. As a net result, the cap leads to an overall decrease in the number of patients who can be covered by the residents on the subspecialty services, forcing hematology programs to create a parallel, non-teaching service.
In the past, the co-existing teaching and non-teaching services contributed to the revolution of “hospital medicine” as a widely practiced specialty. Whether a similar process will occur routinely on inpatient hematology services is yet to be determined. In many centers, hospitalists and mid-level providers are being hired to cover non-teaching hematology services. While it is possible that this arrangement is one way to solve the challenges created by the new ACGME standards, it raises the question of what training and skills are needed for the care of hematology inpatients. This arrangement also brings into the conversation the possibility of creating a new niche — the “hematology hospitalist” that will be focused on inpatient care of hematology patients. Whether the approach to management of hematology inpatients needs to change significantly is debatable, however, awareness of the effects of the recent changes in ACGME standards encourages us to think broadly about this issue.
The role of the hematology fellow is no longer clearly defined in this time of change, but it is clear that hematology training programs will have to adjust to the new structures of the inpatient services. The ACGME core concept of gradual and progressive responsibility for residents will have to be applied to hematology fellow training as well. Program directors can no longer choose between defining the fellow as a “super-resident” or “junior attending”; instead, the training process should reflect a responsibility continuum throughout the fellowship. Defining the desired competencies for fellows in each year of training will most likely be the first step in this direction.
In many programs, the clinical experience of hematology fellows during inpatient rotations will be decreased as a result of creating parallel teaching and non-teaching services. The negative effect on experience of splitting up the inpatient service can be compensated for by giving more responsibility to the fellows during inpatient rotations to maximize the educational value of the rotation. Additionally, the academic curriculum will need to be adjusted to ensure that high-quality formal, didactic training will provide fellows with a reasonable replacement for the less intense inpatient experience. Fellows will need to learn how to communicate and work effectively with mid-level providers. This interaction will be a new experience for most fellows, as involvement with mid-level providers during residency is typically limited. However, the experience will be of value for trainees as mid-level providers work closely with staff physicians in the “real world.”
The mandated changes create an opportunity to improve hematology fellowship programs and better prepare fellows to be independent and confident hematologists, but doing so calls for collaboration between ASH and ACGME to define the goals and competencies for every stage of the fellowship. It also creates an opportunity for fellows to take part in this process on a national scale, helping to design better programs for future generations of trainees.
