Providing residents with a sound academic and clinical education will be carefully planned and balanced with concerns for patient safety and resident well being. It is the policy of our program to ensure that the learning objectives of the program are not compromised by excessive reliance on residents to fulfill service obligations. Didactic and clinical education has priority in the allotment of residents' time and energies.

Residents will be assigned night rotation and weekend duties on a regular basis, as well as adequate and defined off-duty hours. Our duty hours recognize that faculty and residents collectively have responsibility for the safety and welfare of patients.

• Duty hours are defined as all in-house clinical and academic activities related to the residency program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences.

• Duty hours do not include reading and preparation time spent away from the duty site.

• Duty hours will be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities.

The objective of on-call activities is to provide residents with continuity of patient care experiences throughout a 24-hour period.

• In-house call is defined as those duty hours beyond the normal workday when residents are required to be immediately available in the assigned institution. In-house call will occur no more frequently than every fourth night, averaged over a four-week period.

• At-home call (pager call) is defined as call taken from outside the assigned institution. The frequency of at-home call is not subject to the every fourth night limitation. However, 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, averaged over a 4-week period. When residents are called into the hospital from home, the hours residents spend in-house are counted toward the 80-hour duty limit.

• On-call duties during periods of resident shortages caused by illness or leave of fellow residents. Coverage will be provided by a resident using the at risk policy program.

• Back-to-back in-house night call when a resident changes services
  Not permitted.

• Assignment of clinical or educational duties in one hospital concurrent with on-call assignments overnight in other hospitals. This can occur with some outpatient rotations, but not in other circumstances.

• Specified number of periods of 24 or more consecutive hours off duty per month.

1. Residents will be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call. (One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities.)

2. Adequate time for rest and personal activities must be provided. This should consist of approximately a 10-hour time period provided between all daily duty periods and after in-house call.

• Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours.

• Residents may remain on duty for up to 6 additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics and maintain continuity of medical and surgical care.

• No new in-patients may be accepted after 24 continuous hours on duty. A new patient is defined as any patient for whom the service or dept has not previously provided care. However, this rule does not apply to outpatient rotations, nor for the model Family Practice Center. In these two latter settings, new patients may be cared for by a "post-call" resident, as long as the resident is off duty by 30 hours total or less.

• Residents may exceed the 24+6 hour work rules in Family Medicine to complete a continuity obstetrical delivery. However, it is the responsibility of the resident and the program to make immediate changes in the resident’s work schedule following the delivery to provide appropriate off duty recovery time consistent with ACGME work rule guidelines.

  Example #1: A patient seen in clinic, even by another resident, would NOT be a new patient. The resident should evaluate all patients before participating in surgery.

  Example #2: A patient that arrives into the ER (who has never been seen by the service or dept) with an acute myocardial infarction would be a new patient.

  Example #3: Following a 24 hour on call shift, the FM resident goes to an off campus morning outpatient rotation (eg dermatology) or to their model Family Medicine clinic for their usual FMC half-day morning clinic. In either of these settings, the post-call resident may see new or established patients during their clinic.

• It is accepted that during residency training 'pure' continuity is not possible. Thus, residents often see patients in clinic - but don't admit on them. And other residents switch services and follow patients they haven’t cared for before. The idea is that throughout the course of residency training each resident will see enough patients along the continuum of care to learn what is required.

• There is no provision for specific rest periods while on-call due to the nature of patient care. Adequate sleeping areas close to patient wards are provided for residents to use whenever possible.

• Faculty and residents are educated on a regular basis at a Departmental Grand Rounds lecture how to recognize the signs of fatigue and apply policies to prevent and counteract the potential negative effects.

• Back-up support systems are available to residents when patient care responsibilities are unusually difficult or prolonged, or if unexpected circumstances create resident fatigue sufficient to jeopardize patient care.

• This Resident Hours Policy is posted on the Resident Intranet.
  

In the event of resident illness or absence, requiring additional calls being taken by other residents, the chief resident(s) will insure that those who are tasked with additional call duties will not exceed the duty hours guidelines. In the event no resident is available to take call, then the attending physician on duty will assume the call responsibilities.


More Information on Work Hours and Work Hours Tracking

The Department of Family Medicine views the ACGME guidelines as an opportunity to improve resident education while ensuring patient safety and continuity of care.

The new compliance systems will be imposed on the residents and will not be voluntary.

There were previously no limitations for time spent in the hospital and the human tendency is to 'fill the time'. This generally results in an inefficient use of time. In the new system residents will pre-program their day to leave at 30 hours of service maximum.

The Department of Family Medicine will institute 2 new resident performance measures:

• Time management

• Appropriate and safe transfer of patient care: A structured and standardized patient sign-out/hand-off process for the entire system will be created.

Work hours tracking:

• Residents will be personally responsible for tracking and monitoring their work hours and ensuring compliance. Any system problems should be reported to the senior resident on the service, the Chief of the Service and the Program Director.

Hours tracking plan:

• The Chief Resident or senior-most resident on the team plans the weekly schedule to insure compliance with the work hour requirements and verifies the work hours data from each of their team members weekly (Monday -Sunday).

• Residents are required to notify the senior resident if their hours are approaching a potential duty hour violation so that their schedule can be adjusted to avoid excess hours.