ACGME Guidelines for Interns

This morning over breakfast, I discussed the new ACGME guidelines with the ENT resident I’m researching with. Beginning in July, these new provisions will affect all first year residents namely on two fronts – interns won’t be allowed to work shifts in excess of sixteen consecutive hours and an attending physician/senior resident will have to supervise junior residents by either being physically present or on site.

The primary issue these measures are trying to address is medical error caused by interns who are simply burned out from being overworked. By mandating things like uninterrupted five hour naps and capping shifts at sixteen hours, the intention is to drastically reduce preventable mistakes. This is great and all, but I can see it crippling the training of surgeons.

Surgical residency programs are geared towards one thing – case exposure. By essentially limiting the amount of hours interns work, are we not simultaneously limiting the number of unique cases residents encounter on the wards? As an intern, you should be looking to work as much as possible while there are senior residents and attending physicians supervising your work. Once you’re a fully licensed, board-certified surgeon, you’ll rely on your experience to guide your practice – an experience that can only be appropriately tailored with a ridiculous amount of patient encounters and practice.

Next, I would hate to be a senior resident when these guidelines (having to supervise junior residents at all times) go into effect this summer.

So hypothetically if I were on night call as a brand new ENT intern and a patient came in with his neck hanging open after being stabbed, I’d undoubtedly require the help of an upper-level resident or attending. Now let’s say another patient comes in with otitis externa during the same shift. There’s no need for an attending/upper-level resident to physically be present for me to a.) assess the severity of the otitis externa, b.) prescribe a course of Ciprodex and c.) say “Follow-up in the ENT clinic. Have a nice day.” This gives the intern a valuable learning opportunity to assess the patient, provide treatment/follow-up, and relay the info back to the team. Plus, in reality, if it’s 3 AM and a vanilla case of tonsillitis comes in, the upper-level resident will likely want to either split the work or take the case on entirely so everyone can just go home. Multiply this scenario throughout the entire intern year… and that’s a lot of missed learning. Remember, these same interns will be upper-level residents the following year too. ๐Ÿ˜‰

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3 Comments
  1. Mohit says

    Good post man. I agree with your view on the guideline’s effects on surgical interns/residents. However, the 16 hour limit is actually pretty logical, in my opinion, considering that studies have shown that long period of work without rest impair judgement. The supervision part of the guidelines, I think is crazy because if an intern needed help, and a senior resident/attending was not there, pagers still happen to exist. ๐Ÿ˜€

  2. Kevin says

    Interesting. Do you think there would be a similar hit in the number of unique cases seen by IM interns too? Good post, as usual, Rishi!

    1. Rishi says

      Thanks Kevin! Honestly, I’d imagine every flavor of intern would be affected; however, a surgeon’s repertoire of skills (and, in a sense, their livelihood) is profoundly related to the cases they encounter. Less time on the wards = less cases = less experience = less-of-a-surgeon, in my humble opinion.