A panel discussion on the newly mandated resident training rules was conducted by M. Philip Luber, MD, Associate Professor, Director of Education, Department of Psychiatry, University of Maryland School of Medicine; Director of Residency Training, University of Maryland/Sheppard Pratt Program; Karen L. Swartz, MD, Associate Professor, Associate Director for Residency Education, The Johns Hopkins Hospital; Keith Persinger, MBA, Senior Vice President and Chief Financial Officer, University of Maryland Medical Center and University Specialty Hospital; Sarah K. Tighe, MD, Chief Resident, Johns Hopkins University School of Medicine Department of Psychiatry and Behavioral Sciences; Vinay Parekh, MD, Chief Resident, Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences; and Ruby Lee, MD, Chief Resident, Department of Psychiatry, University of Maryland School of Medicine.
The new training changes fall into two categories, duty hour limitations and rules on supervision and are effective on July 1, 2011. The purpose of residency training is to give residents optimal opportunity for training in a safe environment.
The new duty rules recognize the dangers associated with sleep deprivation on both the resident and on patient care. Intermediate level residents must have eight hours between their scheduled duty periods and can only work 16 hours straight. They must have 14 duty hours free following 24 hours of inhouse duty. Because residents in the final years of their education have to be prepared to practice medicine and care for patients over irregular or extended periods of time, their rules are less strict. While it is still desirable to have eight hours of duty free time between scheduled duty periods, there may be circumstances when this is not possible. They can work 24 hours straight but can work an additional six hours wrapping up the work. Working six hours in an outpatient area after a 24 hour shift is not allowable. Residents may not be scheduled for more than six consecutive nights of night float.
The new supervision rules are intended to assure that adequate supervision is available to residents as their training progresses. At the beginning of training the entire interaction needs to be supervised directly. Once the trainee is able to recognize when help is needed, can ask for help, can demonstrate an ability to perform an intake, can complete a history and physical assessment, can deal with safety concerns and present cases clearly, the trainee can be advanced to the indirect level. Indirect supervision allows for the trainee to treat a patient as long as direct supervision is immediately available. The resident might treat the patient and report later about what was done. Residents must care for patients in an environment that gives them the opportunity to work as a member of a multidisciplinary team.
These changes present a challenge to all academic institutions. Who will backfill and provide the level of care? What will be the cost? In Maryland, attendings and nurse practitioners will perform the services that were done by residents in the past. Patients will be seen by two clinicians instead of one. Will these new rules allow for adequate training? Will they have enough experience? There is a significant financial consequence to the changes in resident training. It is an unfunded mandate that is estimated to cost the University of Maryland $3.5M per year. Some fear that further reductions in duty hours might follow.
The impact on staff is significant. The attendings are working longer hours (60-80 hours) without additional compensation, their workload has changed significantly. During this same period they have had to adapt to the electronic medical record. Currently each clinical faculty supervises one or more trainees. Community physicians train residents too. The University of Maryland is considering giving incentives for teaching.
The demand for nurse practitioners continues to grow. Their skill set and salary makes them an attractive alternative to physicians. The time to train a nurse practitioner to work in Psychiatry is significant and they often transfer to another department.
Patients will have a greater number of caregivers as a result of the new rules. There was some discussion about the need for additional communication and increased hand-off of care. The panel participants agreed that there can be a lack of continuity and they have developed formal sign-outs to deal with this.
They estimate that it will take ten years to see the impact of this change.
(Article by Deb Tatchin. Deb is Finance Manager of the U Michigan Department of Psychiatry).
