California CIR Members Leading the Way on Resident Work Hour Redesign

Throughout the state, CIR members are engaged in discussions and, in some cases, pilot programs to determine the best ways to implement the recommendations outlined in the 2008 Institute of Medicine report, Resident Duty Hours: Enhancing Sleep, Supervision and Safety. The ACGME is expected to release new guidelines later this year, and CIR has been weighing in on the best ways to protect doctors and patients on the job.

Dr. Chris Landrigan, a Harvard sleep scientist who has done extensive research on the effects of sleep deprivation on physician and patient safety, spoke to residents at Harbor-UCLA on March 17, 2010. He reviewed the scientific evidence on fatigue and patient safety, and urged residents to start thinking about how their programs could move away from 30-hour call schedules.

"Dr. Landrigan presented a balanced and evidence-based assessment of the issue of resident work hours,” said Dr. Linda Sharp, an Internal Medicine resident at Harbor-UCLA. “With concern for both patient and physician safety, his talk shows us that we need to critically review the way we structure residency training."

Dr. Emil Avanes, another Internal Medicine resident, called the evidence “clear, objective, and overwhelming”  on the risks associated with 30-hour work shifts during residency training. “It was interesting to hear that the post-call hazards I experienced as an intern are also experienced by an extraordinary number of others,” said Dr. Avanes.

In San Jose, the Obstetrics and Gynecology program at Santa Clara Valley Medical Center has developed a pilot program to implement the IOM recommendations, which call for maximum shifts of 16 hours, 12 hours off between shifts, and one full weekend off a month.  

Prompted by the evidence on patient safety and 24-hour shifts, the program director at Santa Clara decided to implement the IOM recommendations before the ACGME made a decision. CIR delegate Dr. Marisa Chavez  said the response from residents has been positive because of the active participation of all residents in the process, with three residents on the Work Hours Committee (one from each year). “There was initial hesitation with handoff times and vacation scheduling,” Dr. Chavez said. Weekly meetings with all residents to discuss proposed changes and resident concerns helped ease the transition.

The major changes were:

• A block schedule, which includes a vacation block which is comprised of 3 weeks with one research week; residents have ability to "swap" vacation weeks with one another so that can space out their vacations during the year.
• Maximum of 80 hours per week; no averaging beginning next year.
• At least one day off (24hrs) per week one 48-hour period off per month.
• Maximum 16-hour shifts; the program decided not to institute 30-hour shifts with a 5-hour sleep period because it was logistically impossible given small the program size.
• Weekday calls eliminated secondary to institution of night float system; weekend coverage by non-night float residents with most residents covering one weekend shift;  ambulatory residents cover Friday night shift and Sunday day shift three times a month and have one weekend off.
• Minimum time off remains at 10 hours after day shift; the program has not yet adopted 12 hours off after night shift (this was a resident decision) because of desire for fair distribution of total hours per week and strong desire to minimize number of patient handoffs; currently night float has 10-11 hours off between shifts.
• Moonlighting not allowed.

Dr. Chavez believes this can be done in other programs as well. “It requires creative thinking, advanced planning, reorganization and consultation with other programs with similar program sizes for schedule models,” she said. “Resident input is very important, as residents know the ins and outs of their schedules and where their training is lacking and can identify areas of improvement.”

For more information on the IOM recommendations, go to the Policy section.