Intern work-hour restrictions? Get a physician extender, night float

By Sarah Guy, medwireNews Reporter

The most common response by surgical chiefs at Veterans Affairs (VA) medical centers to the work-hour restrictions put in place by the Accreditation Council for Graduate Medical Education (ACGME) in July 2011 is to hire a physician extender, report US investigators.

The majority of extenders used were midlevel physicians; either a nurse practitioner or a physician assistant, with surgical hospitalists used in a third of cases, and surgical residents or moonlighters used in the remainder.

Other methods of dealing with the 2011 rules include introducing a night float for residents or interns, establishing early versus late shifts, or establishing cross-institutional or disciplinary coverage, show the survey results.

"The public expects the medical community to produce safe experienced surgeons, while simultaneously demanding they are well rested and directly supervised at all times," say Melina Kibbe from the Jesse Brown VA Medical Center in Chicago, Illinois, and colleagues.

"Given the myriad, and, at times, contradictory pressures on the surgical educational system, the ability to meet these expectations grows ever more difficult," they add, in the American Journal of Surgery.

The ACGME 2011 regulations include that interns cannot exceed 16 hours of consecutive duty and residents cannot exceed 24 hours, and that interns should be supervised either directly or, like residents, indirectly by a qualified physician with direct supervision immediately available.

The regulations require profound restructuring of resident night coverage systems, remark Kibbe et al.

To deal with these implications, 37% of 69 surveyed VA surgical chiefs hired a physician extender to act as a trainee, which introduces potentially significant costs and variation in the quality of intern supervision, depending who that physician is.

However, such costs can be reduced by using surgical resident moonlighters as the extender, which in turn provides them with clinical experience during their sabbatical, suggest the researchers.

The next most common option was to use a night float for residents or interns, reported by 22% and 19% of VA chiefs, respectively. This approach provides a consistent team whose patient census is similar each night and while interns may be responsible for a large number of patients, he or she is unlikely to receive calls for many of them provided the day team has addressed all pending concerns, suggest the authors.

Furthermore, the introduction of night rounds during night float systems can enhance clinical education and improve the unavoidably increased number of hand-offs, they add.

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