Graduate Medical Education
The New ACGME Common Program Requirements: The Impact on Clinical
Faculty
Revised: August 11, 2017
Recently the ACGME has implemented far reaching changes in the
Common Program Requirements which govern all residency programs. For
the first time these CPRs mandate significant changes in the way
faculty interact with and are responsible for the program
activities.Far more than just duty hours. Require institution to
educate faculty in:
- Learning Environment
- Professionalism
- Proper supervision
- Transitions
- Wellness
- Fatigue: facts, mitigation and alertness management
- Educational and work hours
Learning Environment
Faculty must demonstrate an understanding and acceptance of their
personal role in the following:
- Assurance of the safety and welfare of patients entrusted to
their care
- modeling behaviors that show the well being of the patient is
paramount
- explain to the learners why they are making certain decisions
- showing how they monitor and coordinate the care of other
consultants including the use of unwarranted diagnostic or therapeutic
tests or procedures.
- Provision of patient and family centered care
- demonstration of the highest professional behaviors,
- maintaining patient confidentiality especially in public
places,
- not displaying arrogance in dealing with students and patients,
- being conscientious in dealing with patients (not taking
shortcuts, returning calls, etc)
- being altruistic, pointing out conflicts of interest to
learners and how to avoid them and other examples.
- Assurance of their fitness for duty as described in and
accordance with the LSUHSC Fitness for Duty Policy.
- Management of the time before, during, and after clinical
assignments reinforcing healthy lifestyles including sleep hygiene.
- Recognition of impairment, including illness and fatigue,
depression in them
and in their peers.
- Attention to lifelong learning - faculty complete LSUHSC on-line
compliance modules.
- Monitoring of patient care performance improvement indicators.
- Honest and accurate reporting of educational and work hours,
patient outcomes,
and clinical experience data.
- Faculty must reinforce the importance of accurate and timely
reporting of work hours is part of the resident's contract and failure
to do so is grounds for disciplinary action up to and including
termination.
- They must reinforce that case logs and clinical data
reporting are an important part of program accreditation as is their
ability to take certification tests as compliance moves towards
maintenance of certification.
- Faculty members must demonstrate responsiveness to patient needs
that supersedes self-interest.
- Physicians accomplish this by recognizing that under certain
circumstances, the best interests of the patient may be served by
transitioning that patient's care to another qualified and rested
provider.
Professionalism
The Elements of Professionalism required of physicians are:
- Altruism – the best interests of the patient over your own
- Accountability – to patients , society and the profession
- Excellence – consciously exceeding expectations
- Duty – being available, accepting inconvenience and risks when
meeting the needs of the patient. Advocacy of patients interest and
volunteering time and effort to the profession and society.
- Honor and Integrity –
- being fair, being truthful, keeping one’s word
- meeting commitments, being straightforward
- recognizing conflicts of interest and avoidance of
relationships that allow personal gain to supersede the best interest
of the patient
Challenges to the Elements of Professionalism:
- Abuse of Power-
- Interactions with patients and colleagues
- Bias and sexual harassment
- Breach of confidentiality
- Arrogance
- Greed - physicians must continually ask themselves whether their
actions are guided by the best interests of their patients or their own
financial interests
- Misrepresentation - consists of lying and fraud
- Impairment
- Lack of Conscientiousness-
- "failure to fulfill responsibilities"
- a physician who does the minimum
- Conflicts of Interest
Supervision
Expected components of supervision
- Assessing the skill level of the resident by direct observation.
- Faculty members should delegate portions of care to residents,
based on the needs of the patient and the skills of the residents.
- Documenting the supervision which should generally include but
not be limited to:
- progress notes in the chart written by or signed by the faculty
- addendum to resident’s notes where needed
- counter-signature of notes by faculty
- a medical record entry indicating the name of the supervisory
faculty.
- Giving frequent formative feedback and formal summative written
feedback that is competency based and includes evaluation of both
professionalism and effectiveness of transitions.
- Each patient must have an identifiable,
appropriately-credentialed and privileged attending physician who is
ultimately responsible and accountable for that patient’s care.
- This information should be available to residents, faculty
members, other members of the healthcare team and patients.
- Residents and faculty members should inform patients of their
respective roles in each patient’s care when providing direct patient
care.
Teamwork
- Residents must care for patients in an environment that
maximizes communication.
- This must include the opportunity to work as a member of
effective interprofessional teams that are appropriate to the delivery
of care in the specialty.
Transitions
Transitions / Hand Offs
- Transitions of care create the most risk for medical errors.
- Programs must design clinical assignments to optimize transitions in patient
care, including their safety, frequency, and structure.
- In
recognition of this, we have created a transitions policy that includes:
- A minimum format for effective transitions must be witnessed
and
attested to by faculty.
- Provision of a complete and accurate rotational schedule in New
Innovations.
- Presence of a back up call schedule for cases where a resident
can’t complete work.
- The ability of residents to freely and without fear of
retribution report their inability to carry out their clinical duties
due to fatigue or other reasons.
Transition Guidelines
- All programs must ensure and monitor effective hand-over
processes to facilitate both continuity of care and patient safety.
- Programs must ensure residents are competent in the hand-over
process.
- Program
and clinical sites must maintain and communicate schedules of attending
physicians and residents currently responsible for care.
Education of Residents on Effective Transitions
- Most common cause of sentinel event is miscommunication
- Should be face-to-face
- Should be written and verbal communication
- Each program should adopt specialty specific components to hand
offs
- Demographics, diagnoses, current problem list, medications,
pertinent labs, etc.
Well-Being
- Residents and faculty members are at increased risk for burnout
and depression.
- Psychological, emotional, and physical well-being are critical in
the development of the competent, caring, and resilient physician.
- Self-care is a component of professionalism.
- Programs and the sponsoring institution have the same
responsibility to address well-being as we do to ensure other aspects
of residents competence.
- Responsibilities must include the following:
- Efforts to enhance the meaning that resident finds in the
experience of being a physician (protecting time with patients;
minimization of non-physician obligations, provision of administrative
support)
- Enhancement of professional relationships, attention to
scheduling,
work intensity, and work compression that impacts well-being.
- Evaluating safety data and addressing the safety of residents
and faculty members in the learning and work environment.
- Policies and programs that encourage optimal resident and
faculty member well-being.
- Attention to resident and faculty member burnout, depression,
and substance abuse.
- Must
educate faculty members and residents in identification of the symptoms
of burnout, depression, and substance abuse, including a means to
assist those who experience these conditions.
- Recognize symptoms in themselves and how to seek appropriate
care.
- The program and sponsoring institution must
- Encourage residents and faculty members to alert the program
director or other designated personnel when concerned that another
resident, fellow, or faculty member may be displaying signs of burnout,
depression, substance abuse, suicidal ideation or potential for
violence;
- Provide access to appropriate tools for self-screening;
- Provide access to confidential, affordable mental health
counseling and treatment, including access to urgent and emergent care
24 hours a days, seven days a week.
- Each program must have a policy and procedure in place to
ensure coverage of patient care in the event that a resident may be
unable to perform their patient care responsibilities.
Resources
A Case Study
Ana is a second-year resident in a demanding internal medicine
residency program. She is generally regarded as one of the most
talented residents and has just been elected to the chief resident
position for the next year. For several months, however, she has been
feeling a significant amount of burnout. Ana’s mood has become low, her
energy level has dropped and she is having difficulty getting out of
bed in the morning. She is in the middle of a very demanding ICU
(Intensive Care Unit) rotation, during which she is on call every third
night, so at first she thinks that it might just be sleep deprivation
causing the problem. But she continues to feel increasingly unwell both
physically and emotionally.
Ana’s mother was recently diagnosed with breast cancer. Her mother
lives over a thousand miles away, and it’s impossible to visit her,
since Ana only has one day per week off from work. Her mother reassures
her, saying, “Don’t worry about me – keep working.” Nevertheless, Ana
can’t stop thinking about her mother and is having a hard time focusing
on medicine. She has to force herself to complete tasks and she stops
doing the extra reading on medical cases that she usually enjoys. She
is feeling overwhelmed and increasingly hopeless about life.
Ana also feels that she is not able to care for her patients as
well as she used to in previous rotations. The other day when a patient
was admitted with recurrent fainting episodes, she took a brief history
from the patient and did not do a thorough job asking about family
history, missing the fact that both the patient and other family
members had histories of blood clots. As a result, she did not think to
work the patient up for a pulmonary embolus (blood clots to the lungs)
even though he had had some shortness of breath on admission, which is
a common presenting symptom of this dangerous condition. If a colleague
had not thought about this possibility and suggested the requisite
testing, the patient’s life might have been in danger. Ana feels that
if she were doing her usual amount of reading of the medical
literature, she would have been better prepared.
Ana is afraid to tell anyone how she feels because she knows that
people in the program will start to regard her as a “weak” resident if
she complains. Besides, all the other residents are working just as
hard and don’t seem to be having any problem. She will not even discuss
the situation with her family at home because she does not want to
disappoint them. She is feeling completely trapped and wonders why she
went into the medical field in the first place; she would do anything
at this point to escape it.
Is Ana Exhibiting Signs of Burnout?
Yes
No
I.
Fatigue Management/ Mitigation & Alertness Management
Fatigue Facts (modified from American Academy of Sleep
Medicine resources)
- Resident sleepiness levels that can approximate those seen in
Sleep Apnea and even Narcolepsy
- Sleep and wakefulness are highly regulated by the homeostatic
process
- This drives the length and
depth of sleep and the circadian rhythm
which influence timing and duration of daily sleep/wake cycles.
- Most people need 8 hours of sleep a night. Significant cognitive
declines occur with one night of missed sleep.
- Sleep deficits continue until they are made up
- It usually takes 2 nights to do so
- Tasks dependent on high and/or sustained levels of vigilance,
those of longer duration and those requiring newly learned procedural
skills, are particularly vulnerable to short-term sleep loss.
- In sleep-deprived residents, their own patients, nursing staff,
co-workers and family often become the “enemy” because they seem to
contribute to sleep deprivation.
- “Behavioral problems” can be an unrecognized side effect of
fatigue.
Feelings of isolation, depression, vulnerability, motivation, life
satisfaction etc. are well-known feelings that resolve with adequate
sleep.
- After about 16 hours performance deteriorates.
- Self-perception of sleepiness consistently underrates the
degree of sleepiness. Sleepy residents do not recognize they are
sleepy. They may fall asleep briefly (“micro-sleeps”) but studies
indicate residents do not perceive themselves to be asleep almost half
the time
they had fallen asleep. Residents were wrong 76% of the time when they
reported staying awake.
- Sleeping less than 7 hours per day can lead to sleep deficit.
- Chronic sleep restriction to 6 hours or less leads to performance
deficits similar to that seen following total sleep deprivation.
Alertness Management
- Prophylactic naps prior to call improve alertness during call.
- 15 minute naps q 2-3 hours on-call significantly ameliorate
performance decrements, especially between 2 and 9 am
- Naps take the edge off but do not replace sleep.
Driving and Drowsiness
- There is a clear link between driving drowsy and car crashes
- sleeping 5 hours or less increases crashes 4.5 times
- fatigue related crashes more likely to cause injury or death
than other common causes
- Warning signs
- trouble focusing on the road
- difficulty keeping your eyes open
- nodding
- yawning repeatedly
- drifting from your lane or missing signs / exits
- not remembering driving the last few miles
- closing your eyes at stoplights
- Mitigating falling asleep while driving
- don’t drive drowsy – take taxi or other transportation
- 20 minute nap and caffeine before going home
- pull off the road and take nap if any above signs
Pre-Call Sleep Strategies for Residents
- Avoid starting call with a sleep deficit - GET 7-9 hours of sleep
per day
- Avoid heavy meals within 3 hours of sleep
- Avoid stimulants to keep you awake/alert
- Avoid alcohol to help you sleep
- Avoid heavy exercise 3 hours before sleep
On-Call Sleep Strategies for Residents
- Tell your Chief/PD or faculty if you are too sleepy to work
- Nap whenever possible (> 30 min or < 2 hours)
- Best Circadian window is 2-5 PM & 2 -5 AM
- Avoid heavy meals
- Strategic consumption of coffee can be helpful (t ½ 3-7 hours)
- Know your own alertness/sleep pattern!
Post-Call Sleep Strategies for Residents
- Lowest Alertness 6 –11 AM, after being up all night
- Full recovery from sleep deficit takes 2 nights
- Take 20 minute naps or have 1 cup of coffee 30 minutes before
driving
Clinical Experience and Educational Work
- To block a petition filed by AMSA and others that would have OSHA
take over work hour enforcement, and would eventually lead to a
takeover of all graduate medical education, the ACGME revised new work
hour standards.
- The ACGME is very serious about
the absolute enforcement of these standards.
- Enforcement will include unannounced institutional visits.
- Faculty must
know the clinical and educational work hour rules and help
enforce them.
ACGME Work Hour Limits - 2017
2017 Rules |
Maximum hours of work per
week |
- 80 hours, averaged over 4 weeks
|
Maximum Clinical Work and
Education Period Length |
- Must not exceed 24 hours of continuous scheduled clinical
assignments.
- Up to 4 hours of additional time may be used for activities
related to patient safety, such as ensuring effective transitions of
care, and/or resident education.
|
Maximum in-hospital on-call
frequency |
- Every third night, averaged over a 4 week period
|
Minimum time off between scheduled
work periods |
- Must have at least 14 hours free after 24 hours of in-house
call
|
Maximum frequency of in-hospital
night float |
- Must occur within the context of the 80-hour, and
one-day-off-in seven requirements.
|
Mandatory time off work |
- 1 day (24 hours) off per week, averaged over 4 weeks
|
Moonlighting |
- Internal and external moonlighting is counted against
80-hour weekly limit.
- PGY-1s are not permitted to moonlight.
|
Time Off Between Work Periods
Residents must have at least 14 hours free of clinical work and
education after 24 hours of in-house call.
At-Home Call
- Counts towards the 80-hour maximum weekly hour limit…time
spent in hospital or at home performing clinical responsibilities by
residents on at-home call.
- Not subject to the every-third night limitation
- 1 day in 7 free of work, when averaged over four weeks.
- Residents are permitted to return to the hospital while on
at-home
call to care for new or established patients. Each episode of this type
of care, while it must be included in the 80-hour weekly maximum, will
not initiate a new “off-work period."
- Must not be so
frequent or taxing as to preclude rest or
reasonable personal time for each resident.
Any Questions?
For LSUHSC-NO residency programs, please contact the Office
Of
Graduate Medical Education at 568-4006.