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Policies

AMA Policies for Resident Work Conditions Reform

The AMA has extensive policy on reforming the work conditions facing residents.  The following is a selection of pertinent policies.  For more information, please visit the Resident and Fellow Section.

D-310.955 Resident/Fellow Duty Hours, Quality of Physician Training, and Patient Safety
1. Our American Medical Association will continue to monitor the enforcement and impact of the Accreditation Council for Graduate Medical Education duty hour standards, as they relate to the larger issue of the optimal learning environment for residents, and monitor relevant research on duty hours, sleep, and resident and patient safety, with a report back no later than the 2011 Annual Meeting of the AMA House of Delegates. 2. Our AMA will, as part of its Initiative to Transform Medical Education strategic focus, utilize relevant evidence on patient safety and sleep to develop a learning environment model that optimizes supervision, professionalism, communication, and teamwork as well as finding a balance between resident education, patient care, quality and safety, and a wholesome personal life for physician learners and teachers, with a report back no later than the 2012 Annual Meeting. 3. Our AMA (through the AMA GME e-Letter and other communications) encourages publication of studies (in peer-reviewed publications, including the ACGME’s newly developed Journal of Graduate Medical Education) and will promote educational sessions about a) the potential effects of the Institute of Medicine recommendations and b) the effects of duty hour standards, extended work shifts, handoffs and continuity of care procedures, and sleep deprivation and fatigue on patient safety, medical error, resident well-being, and resident learning outcomes, and will disseminate study results to GME designated institutional officials (DIOs), program directors, resident/fellow physicians, attending faculty, and others. 4. Our AMA will call for pilot programs and further research into protected sleep periods during prolonged in-house call and, until such research shows improved patient care and safety, will encourage the ACGME to not adopt the IOM report’s call for a protected sleep period, which could have significant unintended consequences for continuity of patient care and safety, as well as being difficult and expensive to implement and monitor. 5. Our AMA encourages the ACGME to allow appropriate flexibility for different disciplines and different training levels within the current ACGME maximum duty hour standards to best train residents for professional practice within their specialties while optimizing patient safety during their training. 6. Our AMA will communicate to all Graduate Medical Education Designated Institution Officials, program directors, resident/fellow physicians, and attending faculty the importance of accurate, honest, and complete reporting of resident duty hours as an essential element of medical professionalism and ethics. 7. Our AMA will ensure that medicine maintain the right and responsibility for self-regulation, one of the key tenets of professionalism, and categorically reject outside involvement by the Centers for Medicare & Medicaid Services or The Joint Commission and other state and federal government bodies in the monitoring and enforcement of duty hour regulations. 8. Our AMA will urge the ACGME to include external moonlighting hours in the calculation of duty hours, as defined in the IOM report, and also to ensure increased financial assistance for residents/fellows, such as subsidized child care, loan deferment, debt forgiveness, and tax credits, which may help mitigate the need for moonlighting. 9. Our AMA will collaborate with other key stakeholders to educate the general public about the many contributions of resident/fellow physicians to high-quality patient care; further the public should be made aware that residency/fellowship education offers trainees the opportunity to realize their limits (under proper supervision) so that they can competently and independently practice under real-world medical situations. 10. Our AMA will urge that any costs of further duty hour limits be borne by all health care payers, and that any proposed changes to the ACGME standards have adequate funding allocated prior to implementation. 11. Our AMA encourages the American Osteopathic Association to monitor duty hours and related issues in collaboration with the ACGME. 12. Our AMA Council on Medical Education, Resident and Fellow Section, and Young Physicians Section will collaborate in developing a formal response, based on the best evidence for improving resident education as well as patient safety and quality, to the upcoming revisions of the duty hour requirements by the Accreditation Council for Graduate Medical Education. 13. Our AMA encourages the ACGME to allow appropriate flexibility for different disciplines and different training levels within the current ACGME maximum duty hours standards and will work with other key stakeholders to continue to develop strategies for implementing optimal work schedules to improve resident education and patient safety in healthcare. (CME Rep. 2, I-09; Appended: Res. 322, A-10)

D-305.963 Securing Medicare GME Funding for Research and Ambulatory Non-Hospital Based Outside Rotations During Residency
Our AMA will: 1. Advocate for the Centers for Medicare and Medicaid Services (CMS) (both federal Medicare and federal/state Medicaid) funding for the time residents and fellows spend in research, didactic activities, and extramural educational activities required for the Accreditation Council for Graduate Medical Education (ACGME) accreditation during their training. 2. Continue to work with organizations such as the Association of American Medical Colleges (AAMC) and the Council on Graduate Medical Education (COGME), to make recommendations to change current Graduate Medical Education (GME) funding regulations during residency training, which currently limit funding for research, extramural educational opportunities, and flexible GME training programs and venues. 3. Monitor any public and/or private efforts to change the financing of medical services (health system reform) so as to advocate for adequate and appropriate funding of GME. 4. Prepare a Council on Medical Education report for the 2009 Interim Meeting that broadly addresses issues of GME funding that includes examples of successful state and regional innovations. 5. Advocate for funding for training physician researchers from sources in addition to CMS such as the National Institutes of Health, the Agency for Healthcare Research and Quality, the Veterans Administration, and other agencies. (CME Rep. 4, I-08; Reaffirmed: CME Rep. 3, I-09)

H-310.916 Funding to Support Training of the Health Care Workforce
Our American Medical Association will insist that any new GME funding to support graduate medical education positions be available only to Accreditation Council for Graduate Medical Education (ACGME) and/or American Osteopathic Association (AOA) accredited residency programs, and believes that funding made available to support the training of health care providers not be made at the expense of ACGME and/or AOA accredited residency programs. (Res. 913, I-09)

H-310.917 Securing Funding for Graduate Medical Education
Our American Medical Association will: (1) continue to be vigilant while monitoring pending legislation that may change the financing of medical services (health system reform) and advocate for expanded and broad-based funding for graduate medical education (from federal, state, and commercial entities) with a report back to the House of Delegates; and (2) continue to advocate for graduate medical education funding that reflects the physician workforce needs of the nation. (CME Rep. 3, I-09)

H-310.918 Resident and Duty Hours: A Review of the Institute of Medicine Recommendations
Our AMA supports: (1) current duty hour requirements as set forth in the Common Program Requirements, Accreditation Council for Graduate Medical Education, Section VI; and (2) additional study of the issues raised with respect to duty hours in the IOM report and consider further modifications of the current duty hours requirements based on the results of this inquiry. (Res. 327, A-09)

H-310.919 Eliminating Questions Regarding Marital Status, Dependents, Plans for Marriage or Children, Sexual Orientation, Gender Identity, Age, Race, National Origin and Religion During the Residency and Fellowship Application Process
Our AMA:  1. opposes questioning residency or fellowship applicants regarding marital status, dependents, plans for marriage or children, sexual orientation, gender identity, age, race, national origin, and religion.  2. will work with the Accreditation Council for Graduate Medical Education, the National Residency Matching Program, and other interested parties to eliminate questioning about or discrimination based on marital and dependent status, future plans for marriage or children, sexual orientation, age, race, national origin, and religion during the residency and fellowship application process.  3. will continue to support efforts to enhance racial and ethnic diversity in medicine. Information regarding race and ethnicity may be voluntarily provided by residency and fellowship applicants. (Res. 307, A-09)

D-305.963 Securing Medicare GME Funding for Research and Ambulatory Non-Hospital Based Outside Rotations During Residency
Our AMA will:  1. Advocate for the Centers for Medicare and Medicaid Services (CMS) (both federal Medicare and federal/state Medicaid) funding for the time residents and fellows spend in research, didactic activities, and extramural educational activities required for the Accreditation Council for Graduate Medical Education (ACGME) accreditation during their training.  2. Continue to work with organizations such as the Association of American Medical Colleges (AAMC) and the Council on Graduate Medical Education (COGME), to make recommendations to change current Graduate Medical Education (GME) funding regulations during residency training, which currently limit funding for research, extramural educational opportunities, and flexible GME training programs and venues.  3. Monitor any public and/or private efforts to change the financing of medical services (health system reform) so as to advocate for adequate and appropriate funding of GME.  4. Prepare a Council on Medical Education report for the 2009 Interim Meeting that broadly addresses issues of GME funding that includes examples of successful state and regional innovations.  5. Advocate for funding for training physician researchers from sources in addition to CMS such as the National Institutes of Health, the Agency for Healthcare Research and Quality, the Veterans Administration, and other agencies. (CME Rep. 4, I-08; Reaffirmed: CME Rep. 3, I-09)

D-305.960 Loan Repayment for Physicians in State Designated Shortage Areas
Our AMA: (1) will educate membership about various opportunities surrounding loan repayment through mechanisms including but not limited to: a designated state contact, web resources, and informative meetings, so that residents can make an informed decision regarding employment; (2) will advocate equal tax benefits for physicians who practice in either state-designated or federally-designated shortage areas; and (3) acknowledges and continues to support initiatives that facilitate recruitment of physicians to designated shortage areas. (Res. 328, A-09)

H-310.920 Impact of Specialty Board Mandated Residency Completion Dates on Parental Leave During Residency Training
In order to accommodate leave protected by the federal Family and Medical Leave Act, our AMA encourages all specialties within the American Board of Medical Specialties to allow graduating residents to extend training up to 12 weeks after the traditional residency completion date while still maintaining board eligibility in that year. (Res. 326, A-09)

D-310.957 Resident and Fellow Benefit Equity During Research Assignments
1. Our AMA will urge the Accreditation Council for Graduate Medical Education to require accredited sponsoring residency and fellowship training programs to continue to provide comparable benefits to resident and fellow physicians engaged in research activities that are required by either their sponsoring residency and fellowship training programs or residency review committees as if it were full-time clinical service.  2. Our AMA will collect data on resident and fellow physician benefits including resident and fellow physicians engaged in research activities.  3. Our AMA will, through the AMA Resident and Fellow Section, continue to work with residents and fellows and support training of biomedical scientists and health care researchers.  4. Our AMA will advocate that the Centers for Medicare & Medicaid Services include in an expanded cap the FEC count for GME payment formulas the time that resident and fellow physicians spend in research and other scholarly activities that is required by the ACGME. (CME Rep. 14, A-09)

D-310.961 Use of At-Home Call by Residency Programs
1. Our AMA encourages the Accreditation Council for Graduate Medical Education to collect data on at-home call by specialty from both program directors and from residents and fellows and to release these aggregate data annually to the Graduate Medical Education community. 2. Our AMA and the ACGME will collaborate on a survey (similar to those conducted by the AMA in 1989 and 1999) on the educational environment of resident physicians, encompassing all aspects of duty hours, including at-home call. 3. Our AMA will ask that the Council on Medical Education incorporate a review of at-home call issues in the duty hours follow-up report due at the 2010 Annual Meeting. 4. Our AMA will define “at-home” call and its appropriate or inappropriate uses, allowing for flexible solutions from one specialty to the next, with a report back to the House of Delegates. 5. Our AMA encourages the ACGME and the GME community to examine the effects of the increased use of at-home call on resident education and supervision and develop appropriate standards to ensure that appropriate education and supervision is maintained, regardless of the setting. (CME Rep. 5, I-08)

D-310.963 Family and Medical Leave Act Policies for Residents and Fellows
Our AMA:  1. Encourages the Accreditation Council for Graduate Medical Education to study the feasibility of requiring training institutions to offer paid FMLA-qualified leave for residents of no less than six weeks’ duration, and to permit unpaid FMLA-qualified leave of an additional six weeks.  2. Will propose to the American Board of Medical Specialties member boards that they standardize their policies regarding parental leave, absence from training, and the timing of entrance into the board certification examination process, so that at a minimum, all residents are allowed six weeks’ absence of training for FMLA-qualified leave per academic year without disproportionately increasing the length of training, or postponing certification.  3. Opposes requiring residents to serve any more service time than they took in leave that qualifies under the federal Family and Medical Leave Act.  4. Will convene a group of appropriate interested parties, including the ACGME and the ABMS, to discuss options for standardization of FMLA-qualified leave policies that would not disproportionately increase length of training or result in postponement of certification. (CME Rep. 11, A-08)

D-305.966 Reinstatement of Economic Hardship Loan Deferment
Our AMA will actively work to reinstate the economic hardship deferment qualification criterion known as the "20/220 pathway," and support alternate mechanisms that better address the financial needs of post-graduate trainees with educational debt. (Res. 930, I-07)

D-310.967 Resident Pay During Orientation
Our AMA will: (1) advocate that all resident and fellow physicians should be compensated, and receive benefits, at a level commensurate with the pay that they will receive while in their training program, for all days spent in required orientation activities prior to the onset of their contractual responsibilities; and (2) ask the Accreditation Council for Graduate Medical Education to amend its institutional requirements so that institutions are required to compensate resident and fellow physicians, and provide benefits, for time spent in required orientation activities at a level commensurate with the pay that the resident or fellow shall receive while in their program. (Res. 302, A-07)

D-305.967 The Preservation, Stability and Expansion of Full Funding for Graduate Medical Education
1. Our AMA will actively collaborate with appropriate stakeholder organizations, (including Association of American Medical Colleges, American Hospital Association, state medical societies, medical specialty societies/associations) to advocate for the preservation, stability and expansion of full funding for the direct and indirect costs of graduate medical education (GME) positions from all existing sources (e.g. Medicare, Medicaid, Veterans Administration, CDC and others).  2. Our AMA will actively advocate for the stable provision of matching federal funds for state Medicaid programs that fund GME positions.  3. Our AMA will actively seek congressional action to remove the caps on Medicare funding of GME positions for resident physicians that were imposed by the Balanced Budget Amendment of 1997 (BBA-1997).  4. Our AMA will strenuously advocate for increasing the number of GME positions to address the future physician workforce needs of the nation.  5. Our AMA will oppose efforts to move federal funding of GME positions to the annual appropriations process that is subject to instability and uncertainty.  6. Our AMA will oppose regulatory and legislative efforts that reduce funding for GME from the full scope of resident educational activities that are designated by residency programs for accreditation and the board certification of their graduates (e.g. didactic teaching, community service, off-site ambulatory rotations, etc.).  7. Our AMA will actively explore additional sources of GME funding and their potential impact on the quality of residency training and on patient care.  8. Our AMA will vigorously advocate for the contribution by all payers for health care, (including the federal government, the states and private payers), to funding both the direct and indirect costs of GME.  9. Our AMA will work, in collaboration with other stakeholders, to improve the awareness of the general public that GME is a public good that provides essential services as part of the training process and serves as a necessary component of physician preparation to provide patient care that is safe, effective and of high quality.  10. Our AMA staff and governance will continuously monitor federal, state and private proposals for health care reform for their potential impact on the preservation, stability and expansion of full funding for the direct and indirect costs of GME. (Sub. Res. 314, A-07; Reaffirmation I-07; Reaffirmed: CME Rep. 4, I-08; Reaffirmed: Sub. Res. 314, A-09; Reaffirmed: CME Rep. 3, I-09)

H-310.943 Closing of Residency Programs
The AMA: (1) encourages the Accreditation Council for Graduate Medical Education (ACGME) to address the problem of non-educational closing or downsizing of residency training programs; (2) encourages the ACGME to develop guidelines for the institution to follow in such closings or reductions that provide for adequate notification and out-placement service (such as resource contacts, transfer assistance, and financial assistance); (3) reminds all institutions involved in educating residents of their contractual responsibilities to the resident; (4) encourages the ACGME and the various Residency Review Committees to reexamine requirements for "years of continuous training" to determine the need for implementing waivers to accommodate residents affected by non-educational closure or downsizing; (5) urges residency programs and teaching hospitals be monitored by the applicable Residency Review Committees to ensure that decreases in resident numbers do not place undo stress on remaining residents by affecting work hours or working conditions, as specified in Residency Review Committee requirements; and (6) urges institutions that initiate significant reductions in graduate medical education programs (in excess of 20 percent of the trainee complement or in excess of 10 percent of trainees for a given year), or that voluntarily close programs, be requested prior to or at the time of the reduction to file a concise summary of its educational impact with the Accreditation Council for Graduate Medical Education or the relevant Residency Review Committees. (Sub. Res. 328, A-94; Appended by CME Rep. 11, A-98; Reaffirmed: CME Rep. 7, A-06)

H-295.873 Eliminating Benefits Waiting Periods for Residents and Fellows
Our AMA: (1) supports the elimination of benefits waiting periods imposed by employers of resident and fellow physicians-in-training; (2) will strongly encourage the Accreditation Council for Graduate Medical Education (ACGME) to require programs to make insurance for health care, dental care, vision care, life, and disability available to their resident and fellow physicians on the trainees’ first date of employment and to aggressively enforce this requirement; and (3) will work with the ACGME and with the Liaison Committee on Medical Education (LCME) to develop policies that provide continuous hospital, health, and disability insurance coverage during a traditional transition from medical school into graduate medical education. (BOT Action in response to referred for decision Res. 318, A-06)