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The ACGME 80-Hour Rule and PA Education By Rosann Ippolito, MHP, PA-C In 2002, the Accreditation Council for Graduate Medical Education (ACGME) Board of Directors granted preliminary approval to a new set of accreditation standards that limit resident work hours. The final standards for resident duty hours were approved in February 2003 and become effective on July 1, 2003. The impetus for change stemmed from residents’ concerns for patient and physician safety and was based on studies related to the effects of sleep deprivation. ACGME adopted a two prong approach to affect change and assure compliance at both the level of the residency program and that of the sponsoring institution. The standards
(See www.acgme.org/DutyHours/dutyHoursLang_final.asp). There are additional requirements to address moonlighting, supervision, at-home call, and oversight. These standards are applied uniformly across all specialties for the first year of implementation. After the initial year, programs may apply for an exception of up to 10 percent of the weekly 80-hour limit. What are the implications for the PA profession? At the 2002 APAP Education Forum in Miami, Florida, participants discussed several aspects of the new ACGME duty hours standards (see Hot Topics, APAP Update, December 2002). Some of the themes that emerged from the Hot Topics session were that the new standards could impact PA programs, students, and graduates. The possibilities included
According to Ingrid Philibert, ACGME Director of Field Activities, institutions are utilizing several models to address the workforce changes imposed by the new standards: increased responsibilities for faculty physicians and a shift of patient care to midlevel providers, such as physician assistants and nurse practitioners. Employment of nonphysician clinicians has been limited by law and economics — specifically state practice acts and the increased costs associated with the replacement of a resident’s salary with that for a PA or NP. Philibert asserts that the new standards provide an opportunity for the PA community to think about what insights we bring to the table. One department chair in a Boston, Massachusetts, hospital stated that the large residency programs which require a year of research have added patient care responsibilities to that time period, in order to comply with the 80-hour rule. Some residents in these institutions had provided moonlighting coverage at community hospitals, and their call back to the parent institution leaves a significant void. With regard to students, this chair believes that since house staff must depart within six hours of their 24-hour call period, the remaining residents are stretched. This can impact student education, particularly in the early afternoon, as the post-call residents are leaving the hospital. In March, I surveyed a convenience sample of six PA programs across the country to assess the impact of the 80-hour rule. This inquiry was not designed to be rigorously scientific, but rather to provide a snapshot in time. Although the sample size is small, the programs differed across variables such as class size, location (urban vs. rural), and medical school affiliation. Half the programs utilize residents to teach in the didactic curriculum; the courses cited were clinical medicine, psychiatry, physical diagnosis, and radiology. Eighty-three percent of the programs stated that residents participate in the education of PA students during the clinical year. Although not statistically significant, it is interesting to note that none of the respondents had implemented modifications in their program as a result of the new ACGME standards. When asked whether they anticipate any changes following full implementation of the standards in July, respondents mentioned possible increased PA employment, additional PA residency programs, and elevated expectations for PA student performance in clinical sites. These were the same issues that were highlighted at the 2002 APAP Education Forum. Of course, I would be remiss as an educator if I did not state that further study is needed on this topic. What does this mean for PA educators? Anecdotal evidence suggests that the new ACGME standards have created opportunities for the employment of our graduates as adjuncts to the resident team, in fully PA-staffed services, as moonlighters, and in the expansion of PA postgraduate residency programs. With regard to PA programs, the impact of the 80-hour rule remains unclear. Perhaps it will have no impact, or possibly we have not yet witnessed the trickle-down effect. Given the cutback in resident hours, PA programs that place students in clinical sites where residents share the teaching load may find that they must modify the didactic curriculum to prepare students for the increased expectations they will meet in their rotations. Residents may no longer have the time to espouse the teaching philosophy of “see one, do one, teach one.” As the gatekeepers to the profession, PA educators must continue to proactively assess the need for curricular modification, especially in the clinical settings. In addition, we may need to prepare our students for the manpower stresses that the changes may impose within the healthcare delivery system during this time of transition. In the 1978 novel, The House of God, by Samuel Shem, MD, PhD, the author provides a satirical account of the residency experience. Survival tips include Law #11: “Show me a [student] who only triples my work and I will kiss his feet.” The health care delivery system has experienced significant change since 1978 and clinicians are expected to do more with less. The challenge for PA educators is to provide students with the knowledge, skills, and attitudes to hit the ground running in the clinical rotation year. Preparing students who can cut the work of residents in half may no longer be the exception, but the rule.
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| APAP Update - April 2003 |