Wright State University School of Medicine
Sponsored Graduate Medical Education Programs
Resident Manual

Item 208
Resident Working Hours and Supervision
Revised January 2004

1. Resident Working Hours. Recognizing the relationship between resident working hours, quality patient care, and quality education, programs must follow these requirements in regard to working hours for residents and fellows:

1. Duty Hours
1. Residents must work no more than 80 hours per week, averaged over a four-week period. All in-house call is counted towards the working (duty) hour limit. When residents are on call at home and are called into the hospital, the time then spent in the hospital must also be counted towards the weekly hour limit.
   
   
2. Residents should be on-call no more than a mean of every third night.
   
   
3. Residents should have at least 10 hours off duty after each working day. Residents should have a mean of at least one full free day every week.
   
   
4. In emergency room assignments, residents should be scheduled to work a maximum of 12 hours to be followed immediately by 12 hours off duty.
   
   
5. Residents are not required to perform patient care activities outside of the educational program ("moonlighting "). Any moonlighting that occurs within the residency program and/or its primary clinical site(s), i.e., internal moonlighting, must be counted toward the 80-hour weekly limit on duty hours. Moonlighting by residents must be approved by the program director, in compliance with policy 210 Patient Care Activities Outside of the Educational Program ("Moonlighting") and the guidelines of the program; and only if the activities do not adversely affect patient care and the resident's educational program.
2. On-Call Activities
1. In-house call must occur no more frequently than every third night, averaged over a four-week period.
2. 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 to participate in educational activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care.
3. No new patients may be accepted after 24 hours of continuous duty.
4. At home call (page call) is defined as call taken from outside the assigned institution.
• At-home call must not be so frequent as to preclude rest and reasonable personal time for each resident. Residents taking at-home call must be provided with 1 day in 7 completely free from all educational and clinical responsibilities.
• When residents are called into the hospital from home, the hours residents spend in-house are counted toward the 80-hour limit.

2. Resident Fatigue. In residency training, impaired performance means missed opportunities for learning and, at worst, hazards to patients.

1. Fatigued residents typically have difficulty with:
• Appreciating a complex situation while avoiding distraction
• Keeping track of the current situation and updating strategies
• Thinking laterally and being innovative
• Assessing risk and/or anticipating consequences
• Maintaining interest in outcome
• Controlling mood and avoiding inappropriate behavior
2. Signs of fatigue include:
• Involuntary nodding off or waves of sleepiness
• Problem of focusing
• Lethargy
• Irritability or mood lability
• Poor coordination
• Difficulty with short-term recall
  
• Tardiness or absences at work
3. High risk times for fatigue-related symptoms are:
• Midnight to 6:00 AM
• Early hours of day shifts
• First night shift or call night after a break
• Change of service
• First two to three hours of a shift or end of shift
  
• Beginning of residency or new to night call
4. Methods to limit fatigue-related problems include:
• Following the 80-hour limit of the total number of hours worked.
• Establishing a workload that allows for as little variation in work schedules as is feasible. Rapid or frequent shifts from day to night work are known to increase the risk of fatigue.
  
• Creating individualized schedules to accommodate idiosyncratic energy cycles.
  
• Encouraging residents to consult their primary care physicians if daytime fatigue seems out of proportion to the workload. Sleep studies may be warranted.
  
• Obtaining diagnosis and treatment to determine if fatigue is depression or other psychiatric syndrome.
  

3. Graded Supervision. Programs of graduate medical education should produce competent physicians capable of independent practice. Residents and fellows should be able to progress from regular, direct supervision at the start of their educational program to periodic, indirect piloting by its conclusion. Residents must assume progressive responsibility for patient care and recognize their limits, seeking consultation from attendings and supervisors in a timely fashion. First-year residents will be regularly and directly supervised by experienced physicians, including by more senior residents and faculty. Senior housestaff should have well-developed patient care skills, and should require only periodic, indirect supervision.

During their educational program, residents must develop the knowledge, skills and attitudes to deliver patient care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health. A supervisor must continuously assess the skills of residents, the amount of independence to be granted, and the level of supervision required. This supervisory level must assure the provision of safe patient care, maintain expected professional standards, and encourage the pursuit of orderly intellectual and professional growth.

4. Supervision and Individualized Learning Priorities. At the onset of each rotation, supervisors should assess the professional experience of their residents including areas of strength and weakness. This evaluation can start with the review of written evaluations of previous performance, and continue through discussion with the resident as well as close observation of early performance in all phases of patient care. Each educational rotation should be individualized and emphasize areas where residents need more attention to achieve ideal patient care skills. The supervisor and the resident should jointly formulate those learning objectives. The supervisor should also recognize individual differences among housestaff, such as special areas of interest, and compensate for them. Residents should know the goals and objectives they are expected to achieve during the rotation.

5. The Supervisor's Role. The supervisor should motivate residents toward independent learning, self-reliance, and intellectual competence, as well as cultivate curiosity, critical thinking, and mature understanding. Residents need assistance in evaluating, integrating and correlating clinical information. They must solve problems at the highest taxonomic levels. Supervisors should articulate the thought processes used in problem solving so that residents can develop their individual analysis and synthesis processes. The supervisor should help residents learn with clear instruction that correlates with their levels of understanding.

The supervisors should be readily available to guide and support residents with patient responsibilities, and must recognize that the faculty and residents have collective responsibility for patients' safety and welfare. When approached by residents about patient care problems, the supervisor should be helpful and considerate. The supervisor should actively encourage questions, opinions, and comments. Learning is enhanced by reasonable flexibility and the willingness to allow discussion of alternative ideas of management suggested by housestaff. The supervisor should discuss patient care problems with residents to stimulate profound thought. New psychomotor skills should be demonstrated first by the supervisor, and then performed by residents under observation until they attain proficiency.

The supervisor should recognize the resident's concurrent personal, ethical, and social development. Residents need to develop an individual system of productive self-assessment and self-confidence. These attributes can be facilitated by an observant, thoughtful, and dedicated supervisor. The supervisor must monitor for signs of resident fatigue, and intervene to assure safe patient care, and learning.

6. Evaluation of Performance and Feedback. Resident performance evaluation, and provision of feedback should be continuous processes. The supervisors should use fairness, patience, and tact, always treating housestaff with respect. The supervisor should observe while housestaff perform procedures, interact with them during rounds and conferences, evaluate them in all aspects of patient care, and then provide them with constructive critique and helpful suggestions. All supervision must be done in a tactful and confidential manner. Written evaluations should be precise and honest and include detailed descriptions of actual observed performance. Performance evaluations should be discussed with and acknowledged by residents and communicated only to appropriate administrators of the program.

7. Monitoring of Duty Hours. Each program must have written policies and procedures consistent with the ACGME Requirements for resident duty hours and the working environment. Monitoring of duty hours is required, at sufficient frequency to ensure compliance with the Common Program Requirements regarding Duty Hours, as well as individual Program Requirements.

Each program is required to submit in writing, on at least an annual basis, its monitoring report for the past and upcoming plans for the next year. The program's annual report must include data obtained through the program's duty hour compliance efforts, areas of potential non-compliance, and plans for addressing any problems identified, including needed resources.

8. Duty Hour Exemption. The GMEC is completely committed to conducting excellent programs of graduate medical education in conformity with current ACGME duty hour standards. Requests by individual programs for exceptions to the current ACGME duty hour requirements will only be entertained when it can be clearly shown that the exception is necessary for educational reasons. The GMEC must review and endorse any program's exemption request before the request is submitted to the program's RRC. Only programs accredited in good standing, i.e., without a warning or a proposed or confirmed adverse action, may request that an exemption be considered.

The program director must submit a written request for GMEC review. The program's responsibility is to make a clear showing that the exception is necessary for educational reasons. The proposal from a program to the GMEC must include the following documentation:

1. Patient Safety: Information must be submitted that describes how the program will monitor, evaluate, and ensure patient safety with extended resident work hours.
   
2. Educational Rationale: The request must be based on a sound educational rationale which should be described in relation to the program's stated goals and objectives for the particular assignments, rotations, and level(s) of training for which the increase is requested. Blanket exceptions for the entire educational program should be considered the exception, not the rule.
   
3. Moonlighting Policy: Specific information regarding the program's moonlighting policies for the periods in question must be included.
   
4. Call Schedules: Specific information regarding the resident call schedules during the times specified for the exception must be provided.
   
5. Faculty Monitoring: Evidence of faculty development activities regarding the effects of resident fatigue and sleep deprivation must be appended.
   
6. Program improvement: Evidence of improvement related to citations from the last program review, either internal or by the RRC, must be included.

If approved by the GMEC, the GMEC Chair and the DIO will sign a letter documenting GMEC endorsement. This letter, together with this policy, must be included in the RRC proposal.

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