OSHA may crack down on sleepless doctors
Considering petition on long work hours
The problem of fatigued medical residents has gotten the attention of the U.S. Occupational Safety and Health Administration.
Public Citizen, a consumer and health advocacy group, the Committee of Interns and Residents/SEIU Healthcare, a union that represents resident physicians, and the American Medical Student Association petitioned OSHA to regulate work hours of medical residents and got a surprising, same-day response.
"We are very concerned about medical residents working extremely long hours, and we know of evidence linking sleep deprivation with an increased risk of needle sticks, puncture wounds, lacerations, medical errors and motor vehicle accidents. We will review and consider the petition on this subject submitted by Public Citizen and others," Assistant Secretary of Labor for OSHA David Michaels, PhD, MPH, said in a statement.
"It is clear that long work hours can lead to tragic mistakes, endangering workers, patients and the public. All employers must recognize and prevent workplace hazards. That is the law. Hospitals and medical training programs are not exempt from ensuring that their employees' health and safety are protected," he said.
The petition, which was also signed by some leading physicians in sleep medicine or preventive medicine, asks for a maximum of 16-hour shifts and 80-hour work weeks for all medical residents. It was submitted about two months after the Accreditation Council for Graduate Medical Education [ACGME] released proposed standards that include new limits on duty hours that emphasize greater limits on first-year residents.1 An ACGME task force drafted the proposed standard after considering oral and written testimony from medical organizations and others.
At issue: How long can medical residents work without suffering from fatigue that can increase medical errors, decrease patient safety, and impact the doctors' health and safety? Who should regulate those work hours the accrediting body that oversees medical education or OSHA?
"[ACGME] is not doing a good job of keeping the residencies compliant with the rules," says Charlie Preston, MD, MPH, a health researcher at Public Citizen and medical resident in the Department of General Preventive Medicine at the Johns Hopkins School of Public Health in Baltimore. "We need a governmental body to regulate, like we do in other industries."
However, ACGME asserts that it should be responsible for monitoring resident duty hours as a part of the broader focus on quality medical education. ACGME also plans to implement an annual Patient Safety and Quality Assurance review of every institution that sponsors residency programs.
"ACGME strove to make the new standards evidence-based, and to make them reflect the experience and best practices of the medical profession," ACGME said in a statement. It noted that OSHA had rejected a previous petition in 2002.
Should feds step in?
Fatigue clearly can lead to worker errors, and in some industries trucking, airline, nuclear power the public expects governmental limits on work hours to protect the public. Studies also show that fatigue can increase medical error rates, motor vehicle crashes, and needlesticks.2,3
"If policy is to be based on evidence and not opinion, the federal government is obligated to protect resident physicians and their patients by reducing resident physician work hours," the advocacy groups state in their petition. (The petition is available at www.wakeupdoctor.org.)
ACGME acknowledged the concerns about fatigue, alertness and error, but noted that the evidence is clearest for first-year residents (interns). The proposed ACGME standard places greater limits on interns than on other medical residents.
The OSHA petitioners oppose that two-tiered system, noting that fatigue is a biological issue. "We would just say that sleeplessness and fatigue applies to everybody," says Preston. "It's possible interns may make more mistakes when they're sleep-deprived than upper-year residents, but it's still unsafe for those groups."
The ACGME task force on duty hours raised the concern that residents wouldn't use their extra hours to sleep and emphasized that the rules must be part of a well-supervised, quality educational program.
"Illness and the need for medical care are unpredictable, and circumstances arise when physicians must overcome fatigue to help patients in need," ACGE task force members said in the New England Journal of Medicine. "Even more important is the obligation of resident physicians to realize the effect that activities outside the program have on their alertness when in their roles as learners and providers of care."
The advocacy groups note that past efforts by ACGME resulted in poor compliance and little improvement. A study of the working hours of 4,015 interns found that 84% worked longer hours than allowed by the ACGME standard.4
In its 2009 report, Resident Duty Hours: Enhancing Sleep, Supervision and Safety, an Institute of Medicine panel cited gaps in compliance with the ACGME standard that left residents "susceptible to acute and chronic sleep deprivation."5
ACGME has acknowledged "the need for enhanced measures to promote compliance," but says annual site visits would ensure "provision of a safe and effective environment for care and learning."
References
1. Nasca TJ, Day SH, Amis ES Jr; the ACGME Duty Hour Task Force. The New Recommendations on Duty Hours from the ACGME Task Force. N Engl J Med 2010. Available at www.nejm.org/doi/pdf/10.1056/NEJMsb1005800. Accessed on Sept. 21, 2010.
2. Barger LK, Cade BE, Ayas NT, et al. Harvard Work Hours, Health, and Safety Group. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med. 2005;352:125-134.
3. Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of Medication Errors Among Depressed and Burned Out Residents: A Prospective Cohort Study. BMJ 2008;336:488-491. Epub 2008 Feb 7.
4. Landrigan CP, Barger LK, Cade BE, et al. Interns' compliance with accreditation council for graduate medical education work-hour limits. JAMA. 2006;296:1063-1070.
5. Institute of Medicine. Resident duty hours: Enhancing sleep, supervision, and safety. National Academies Press, Washington, D.C., 2009.
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