Duty
Programs are required to monitor duty hours with frequency sufficient to ensure an appropriate balance between education and service and to be able to prospectively identify compliance issues that may exist or that require corrective action.
Back-up support systems must be provided when patient care responsibilities are unusually difficult or prolonged, or if unexpected circumstances create resident fatigue sufficient to jeopardize patient care.
Program compliance with all duty hours rules and requirements will be regularly monitored at the institutional level. Recurring or frequent violations with any aspect of the duty regulations will not be tolerated.
Urology resident duty hours are set with the goal of providing optimal patient care 24 hours a day, seven days a week, while still allowing residents an appropriate amount of time free of clinical responsibility. Duty hours are defined as all clinical and academic activities related to the Urology residency program, (ie. Patient care; both inpatient and ambulatory), 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, presentations, etc.
The department of Urology will monthly monitor duty hours and adjustments will be made accordingly to address excessive service demands and/or resident fatigue. Further information regarding duty hour policy can be found on the ACGME website.
In compliance with the duty hour requirements set forth and revised by the ACGME Board of Directors and the University of Michigan Medical Center, as of July 1, 2011:
- Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities.
- Residents must 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.
- Adequate time for rest and personal activities must be provided. This should consist of a 8-hour time period (intermediate- level residents, Uro1 and 2) provided between all daily duty periods and after in-house call.
Daily Schedule
Residents on each service (U-M Adult, Pediatrics, VA) round as a team each weekday. Rounds begin between 6 am and 7 am, depending on the patient census and whether there is a 7 am conference scheduled on a particular day. When not on call, residents are free of clinical responsibility after they have finished in the operating room or clinic; have seen the inpatients on their subspecialty service with the appropriate attending on afternoon rounds; have seen or followed-up on consultations with appropriate staff; and have completed dictation of their operative and clinic notes. On weekends, the on-call, post-call, and chief residents make rounds on the inpatient services, and complete the necessary work.
On-Call Activities
The objective of on-call activities is to provide residents with continuity of patient care experiences throughout a 24-hour period.
- Continuous on-site duty must not exceed 24 consecutive hours. Residents may remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care as defined in Specialty and Subspecialty Program Requirements.
- At-home call is defined as call taken from outside the assigned institution. The frequency of at-home call is not subject to the every third 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 limit.
- The program director and the faculty must monitor the demands of at-home call in their programs and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue.
Intern Call
PGY-1 (Urology Prelim) and PGY-2 (Urology 1) residents share responsibility for the inpatients on the general care floor and intensive care unit. They alternate answering calls regarding inpatient care during the day. They cross cover with the PGY-2 at the VA for night call. They do not take calls from outpatients. In-hospital call may be required at times, [Urology Prelim, PGY 1 is mandatory in house call] such as when a patient is critically ill or unstable.
Junior and senior residents (Urology-2 and Urology-4) are responsible for emergency room (ER) consults and consults from other inpatient services on an every third or fourth night basis. They are also responsible for answering outside patient calls to the hospital.
Chief residents are on backup call for their inpatient service every night. This means that they are available by pager to answer questions from the Uro-Prelim or Uro-1 covering the inpatients on their service, or to assist with an emergency involving an inpatient from their service. Chief residents also rotate on “Chief Call” every third night, backing-up the junior and senior residents who are on ER and consult calls.
Free Time
University of Michigan hospital policy states that each surgical resident is entitled to one complete weekend per month and one day in seven free of clinical responsibility. In reality, there are enough residents on the urology service to ensure that most residents have at least two weekends off per month. The only exception to this rule is the chief resident, who by the nature of his or her responsibilities, may only have one weekend off.
Day Off Policy
This policy is to define the procedure required of residents who request anurgent/emergent day off. Days off are to be reserved for only urgent or emergent circumstances (eg. family emergencies) and may not result in more than 3 consecutive days off of work or 5 days/academic year.
Procedure for junior HO’s:
Junior level HO’s (II, III): Must contact the senior level resident on the service regarding the circumstances of the request for day off. The senior level resident then may contact the administrative senior level resident (adult urology resident) to inform them of the request. Notification must be made before the HO is scheduled for that day’s work schedule. Timely notification is required to allow the chief resident to modify the resident coverage schedule for that day.
Procedure for upper level HO’s (IV, V, VI): Must contact the faculty on that service regarding the circumstances of the request for the day off. Notification must be made before the HO is scheduled for that day’s work schedule.
Procedure for research HO: Must contact the research mentor regarding the circumstances of the request for the day off.
Questions should be directed to the Program Director.
2005 Approved by Residency Education Committee
Maximum Hours of Work per Week
Duty hours must be limited to 80 hours per week, averaged over a four week period, inclusive of all in-house call activities and all moonlighting.
Note: Averaging must occur by rotation by one of the following: a four-week period; a one-month period (28-31 days); or the period of the rotation if it is shorter than four weeks. When rotations are shorter than four weeks in length, averaging must be made over the shorter assignments. The rotation with the greatest hours and frequency of call must comply with the duty hour requirements. Compliance with the duty hours must not be based on a rolling average. Vacation or leave days must not be included in the calculation for determining duty hours, call frequency or days off.
Mandatory Time Free of Duty
Residents must be scheduled for a minimum of one day free of duty every week (when averaged over four weeks). At-home call cannot be assigned on these free days.
Maximum Duty Period Length
- PGY – 1: Duty periods of PGY-1 residents must not exceed 16 hours in duration.
- PGY-2: Duty periods of PGY-2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital.
- Residents in final years of education (as defined by Review Committee): While it is desirable that residents in this category have eight hours free of duty between scheduled duty periods, there may be circumstances (as defined by the Review Committee) when these residents must stay on duty to care for their patients or return to the hospital with fewer than eight hours free of duty. Such instances must be documented by the resident/fellow and monitored by the program director. Regular and frequent institutional monitoring will also occur.
Minimum Time Off between Scheduled Duty Periods
- PGY-1 residents should have 10 hours, and must have eight hours, free of duty between scheduled duty periods.
- Intermediate-level residents [as defined by the program-specific Review Committee]
- Intermediate-level residents should have 10 hours free of duty
- Must have eight hours between scheduled duty periods.
- Must have at least 14 hours free of duty after 24 hours of in-house duty.
- Senior Residents (in the final years of education [as defined by the Review Committee])
- Preparation for unsupervised practice must occur within the context of the 80-hour, maximum duty period length, and one-day-off-in-seven standards.
- When circumstances require it, senior residents may remain on duty to care for patients or return to the hospital with fewer than eight hours free of duty. In these instances, which should be infrequent, the resident must make a note to this effect in the duty hours log.
- The program director is required to monitor and maintain documentation of circumstances of return-to-hospital activities with fewer than eight hours away from the hospital by senior residents
Duty Hours Exception
Programs interested in extending the duty hours for a subgroup of the residents in the program (e.g., chief residents) or for individual rotations or experiences can use the 88-hour exception to request an increase of up to 10% in duty hours on a program-by-program basis. Most ACGME Review Committees do not permit programs to use the 10% exception. Neurological Surgery and Orthopaedic Surgery are the only Review Committees that allow exceptions. Programs must submit a written request to the GME Committee for up to an exception. The exception must be based and focused on a sound educational rationale and not reflect a service need. Documentation submitted to the GMEC for the review of the exception must include the following:
- Educational rationale for the exception and detailed description of impact if exception is not approved.
- Documentation of how patient safety will be addressed and ensured with extended work hours
- Plan for faculty to actively monitor residents stress and fatigue
- Duration of the exception; not to exceed a one-year period
- Resident in-house call schedules for the previous 30-day period
- Rotation schedules for the previous 30-day period
- Faculty schedules for the previous 30-day period
- Written support from at least two program residents and program chief resident.
- Patient population and case mix data from the previous 60-day period
- Resident moonlighting approval forms
- Signature of the program director and department chair
- Sample schedule should be provided at the time of the request
Also see GMEC Resident Duty Hours and the Working Environment policy: Approved September 2011
Duty Hour Overage
There are times in which residents may remain beyond their scheduled hours due to conditions such as the following:
1) Increased need for patient care due to worsening patient condition and need for closer monitoring
2) Surgical case which takes longer than originally planned
3) Complex unusual case which provides extraordinary learning opportunity
4) Organization of care team by the Chief Resident
Residents who are involved in these clinical scenarios may without penalty be allowed to be in non-compliance with scheduled duty hours or with the mandatory rest period. Residents who are in these situations will be asked to complete a short form which explains the clinical need for working extra hours. These will be reviewed by the PD and the Associate PD for justification
