Reduced resident work hours: Tough enough?
Residents, consumer groups want legislation
Responding to growing criticism that overworked medical residents are compromising patient care, the Accreditation Council for Graduate Medical Education (ACGME) in June passed new work-hour restrictions limiting residents to no more than 80 hours a week.
For residents used to working more than 100 hours per week, often 36 hours straight, the new rules will represent a significant change. But is it a change for the better?
Critics on both sides of the resident work-hour debate are questioning whether the new rules actually will improve patient safety. Proponents of restrictions say the ACGME regs are too vague and easy to dodge. Opponents claim stringent limits will harm patients by reducing continuity of care and adversely affecting the training new physicians receive.
"Residents have traditionally worked long hours. The difference now is that they are actually awake and working almost the entire time," says Eric Hodgson, MD, national president of the Reston, VA-based American Medical Student Association (AMSA), which has advocated for work-hour limits for the past two years.
"Before, they would have to be in the hospital for hours at a time, but they would have time to rest. Now patients are sicker, spend less time in the hospital, and the amount of paperwork required has increased. So the total hours are the same, but the hours of rest during that time are almost nil."
The 2000 Institute of Medicine report, To Err is Human, which estimated the annual number of patient deaths attributable to medical errors, was a wake-up call to the public, leading to increased scrutiny of the working conditions and practices in hospitals, he says. The work-hour limits are a natural extension of that effort.
"I am going into obstetrics and gynecology, and I know that you can be awake for 36 hours nonstop and work the entire time," he explains. "I don’t think it is much of a stretch of the imagination to realize that if you are working 36 hours straight, you are not functioning at your best. It is not just whining doctors wanting better lifestyles. It really is an issue of making sure that patients are being appropriately cared for."
The new ACGME guidelines would limit residents to working 80 hours per week, no shifts longer than 30 hours, and guarantee at least one day off for every seven days worked.
However, the ACGME allows programs to average the rules over a month’s time, Hodgson says. So a resident could be compelled to work a 100-hour week and then be given time off at the end of the month to compensate. The same is true for days off.
"I could have four days off in one week, then be on call every other night for a month," Hodgson says. "That would defeat the whole purpose."
Enforcement is a concern
The new ACGME requirements have too many outs for programs that find the limits too restrictive, and the organization has too little power to truly enforce its rules, says Peter Lurie, MD, deputy director of the Health Research Group of the consumer advocacy group Public Citizen.
"The fact is, it’s not really an 80-hour work limit. It is an 80-hour limit, plus 10% extra time in certain circumstances, six hours of extra time for transferring patients, etc. Plus, there is a provision for a complete exemption if a particular specialty decides it is problematic," he says. (See summary of provisions in the box, above.)
The council also does not make any of its inspections or surveys of particular programs public, so there is no real way to monitor compliance. And, they also don’t have the power to issue fines or any other punishment in order to compel compliance, he adds.
Federal legislation or some other outside enforcement is needed to truly remedy the situation, say both Lurie and Hodgson.
In November of 2001, Rep. John Conyers (D-MI) introduced the Patient and Physician Safety and Protection Act in the U.S. House of Representatives. The measure requires an 80-hour limit, with no average over two or four weeks; at least 10 hours off between shifts; one full day off in every seven; and residents may not be on call more often than every third day.
The bill currently has bipartisan support with more than 60 co-sponsors and has now been introduced in the Senate as well, Lurie says.
In addition, Public Citizen believes that the U.S. Occupational Health and Safety Administration (OSHA) also should have enforcement jurisdiction over residency programs because they are charged with ensuring safe conditions in the workplace.
In April 2001, Public Citizen petitioned OSHA to place limits on resident work hours. The organization presented scientific data showing that longer work hours contributed to resident burnout and workplace problems as well as compromised patient care.
"We got a very general letter back from them saying they would look into it," Lurie recalls.
AMA proposes oversight, opposes legislation
The American Medical Association (AMA) recently passed its own policy on limiting resident work hours that is similar to the ACGME regulations but would limit shifts to 24 hours and would allow averaging time off only over two weeks, says Peter Watson, MD, a medical resident and member of the AMA’s board of trustees.
The AMA is in favor of limits on resident work hours, but is concerned that the limits still allow sufficient time for residents in time-intensive specialties to get the education they need, he continues.
"Physicians in general work pretty long hours, whether they are in training or out in practice. Although, certainly, residents in training do tend to work longer than those in practice, especially in the surgical field," he says.
The new guidelines, both those of the AMA and ACGME, essentially just establish a uniform work-hour standard across all medical specialties, which makes it easier for programs to establish limits and easier for the ACGME to monitor compliance, he says.
"The guidelines that have been set forth are very similar to the guidelines that have already been imposed on internal medicine residents," Watson explains. "But prior to June, each specialty had its own work-hour standard."
The internal medicine standard, which limited residents to 80 hours, was one of the more stringent and explicit standards, with set limits on hours that could be worked in a row and number of days off in a week, etc., he notes.
The standards for other specialties were often much more vague.
"The surgical work-hour standard, the first line of it read: Patient continuity of care takes precedence regardless of hours worked, days off, etc.’ So they kind of set the tone there," Watson says. "Farther down, it does state that it is desirable that residents be on call no more than every third night and get one day off in every seven.’ But clearly, they were qualifying that time standard."
The ACGME became aware that there were inconsistencies in the time that residents were being asked to work, depending on the specialty they were in.
"They recognized that fatigue affects you regardless of the specialty you are in and probably there should be a uniform standard, which I think is a good move," he says.
The internal medicine standard was used, not because 80 hours a week is some magically established safe number, but because that specialty’s standard was largely agreed upon and most internal medicine programs had demonstrated an ability to comply with it, Watson notes.
Most residency programs were in compliance with their specialty-specific residency requirements prior to the June ACGME decision, but the requirements were not uniform.
However, between 30%-35% of surgical residency programs were found to be noncompliant each year, even under the old guidelines. It is these programs that need serious monitoring and reform, he adds.
As a parent member of the ACGME, the AMA has members on the ACGME board and supplies the members of the council’s residency review committees, which inspect and monitor the compliance of individual residency programs.
The AMA has put the ACGME on notice that it is closely watching how well the new work-hour standard is enforced and will take other action if enforcement is lax, he states.
"Enforcement is an issue that the AMA is very concerned about," he continues. "Although we are supportive of their new guideline and our members who are on their board will push to see the standard is applied in an adequate way, we also have some concerns about how it will be enforced."
They have been encouraged that the council has announced that it plans to increase the frequency that programs, especially those that have had problems in the past, are reviewed. And they are instituting more anonymous surveys of residents in the programs so that people feel able to report problems without compromising their work position.
"They do still have a stepwise process for penalizing programs that are in noncompliance, which includes everything from more frequent review all the way to putting them on probation, meaning they are at risk of losing their accreditation, to taking away accreditation altogether," Watson says. "That would mean losing the ability to have a program in that specialty at all."
The best example of this is the Yale-New Haven (CT) Hospital’s general surgery program that recently put on notice that they are at risk of losing their accreditation to train residents in surgery, Watson says.
"The problem was related to excessive work hours," he adds. "Everyone is watching to see what kind of changes Yale makes and whether they lose their accreditation if they are still found to be in noncompliance."
If the ACGME proves unable to enforce the new guideline, the AMA would then consider supporting other measures — including federal legislation, which it currently opposes.
"Our first preference is to keep this under the ACGME because they can act much more quickly than a legislative body can," he says. "The proposed legislation is more than a year old and still in Congress. I see legislation as a method of last resort."
As a medical resident himself, Watson has more confidence in the ability of other physicians to recommend appropriate workplace regulations than federal lawmakers.
"We want better working situations for health care workers and a safer place for patients, and we think we can do this through the accreditation process," Watson says.
However, the AMA and ACGME have both been urged for years to support work-hour limits and have not, says Hodgson. It is only since federal legislation was proposed that both agencies have made significant progress toward reform.
"The medical community has had decades to address the problem and they have not," Hodgson says. "When things are not enforced by an outside body, they tend to not really change."
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Resident Work Rule Proposals Below is a summary of different proposals to limit medical resident work hours: ACGME regulations:
AMA policy:
Patient and Physician Safety and Protection Act:
Source: American Medical Association, Chicago. |
Sources
- Eric Hodgson, MD, American Medical Student Association, 1902 Association Drive, Reston, VA 20191.
- Peter Watson, MD, American Medical Association, Board of Trustees, 515 N. State St., Chicago, IL 60610.
- Peter Lurie, MD, Public Citizen’s Health Research Group, 1600 20th St. N.W., Washington, DC 20009.
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