Impact of restricted duty hours on nephrology fellows

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The Accreditation Council for Graduate Medical Education (ACGME) continues to restrict resident duty hours in an effort to improve patient care related to resident fatigue. These restrictions are beginning to impact fellowship training as the shift in workload moves from interns to residents to fellows. 

2003 (my intern year) was the initial implementation. The 80-hour work week averaged over 4 weeks and the 24+6-hour rules were put into place (new pt. admits for the first 24hrs, but the last 6hrs just dealing with old pts.). I believe these were good initial steps. Working 30+ hour shifts every 4th day is quite taxing on the body and mind and could not have been good for patient care. However, other issues became evident that were not anticipated. First, many residency programs shifted to a “night float” system. Which in reality is just “shift work”. The problem was in the patient “handoff” from one shift to the other. Physicians in-training were not as well versed in making succinct and meaningful patient handoff’s to oncoming teams and this in and of itself can lead to medical errors. The second problem is that the work still has to be completed and new residents were NOT in the agenda (and they still aren’t). In fact, the number of internal medicine residents have remained stable over the last several years

Hospitalist programs have emerged in academic medical centers to help cope with the increasing case load– I can hardly recall an academic Hospitalist program prior to 2003. The popularity in hospitalist programs continues to increase each year. 

Nephrology, cardiology and pulmonary critical care fellowships are all in vulnerable positions as each are assigned a significant amount of inpatient  service. This position of vulnerability is only going to get worse as the duty hour restrictions get even tighter on July 1, 2011. During this iteration interns will only be able to work for 16 straight hours and 2nd and 3rd year residents will need to leave after 24-hours of continuous duty. For a comparison of 2003 and 2011 ACGME duty hour policies click here. Who is going to fill in the void?  Many nephrology training programs are beginning to take more inpatient responsibility. This is of concern because more time on the inpatient service means less time on outpatient rotations. Outpatient training in fellowship programs is critical to producing well-trained doctors.

Secondary to these issues RFN conducted a poll before the July 2011 rules change went into effect to see how nephrology fellows are currently impacted. Interestingly there seemed to be two different opinions. Either no change in work load or an actual increase in perceived workload compared to residency. I can only speculate as to why these two different opinions exist.  It could be secondary to the different types of nephrology training programs (research oriented vs. clinically focused).  Or could be due to the difference in work load allocation (e.g. strong hospitalist presence vs. light hospitalist presence).  I will be interested to see how the new changes will impact duty hours in nephrology, but also cardiology and pulmonary/critical care.  RFN will conduct another poll after the new duty hours rules are put in place. My hope is that nephrology program directors with strive to preserve the outpatient experience. Furthermore, nephrology is already finding it difficult to recruit interested applicants into the field. Further increases in the already busy nephrology fellowship schedule will only make it more difficult.   

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