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After years of discussion, the system of training resident physicians in the United States has finally undergone substantial changes. As of July 1, 2003, more but not all residents were limited to 80 hours of work per week, averaged over a four-week period. The new requirements are part of a general effort to improve the safety of patients and the working conditions and education of residents. They are also designed to forestall federal regulation that could take away some of the authority of the Accreditation Council for Graduate Medical Education (ACGME), the organization that accredits residency-education programs. The debate within the medical profession about how to balance the needs of patients and residents is far from settled, however. Some believe that the new requirements are too weak and marred by loopholes (such as an exception that could increase the weekly limit to 88 hours) and that the ACGME is not up to the task of enforcing the requirements and monitoring compliance.
Others believe that the requirements are too strong and inflexible. For teaching hospitals, the work-hour limits are an unfunded mandate. If these hospitals do not comply with the requirements, they jeopardize their ability to sponsor residency programs and millions of dollars in payments from Medicare for graduate medical education. In order to comply, however, many hospitals will have to redesign their residency programs, hire additional staff members, and make other expensive changes.
In this report, I discuss the debate over residents' work hours and the challenges involved in establishing and enforcing limits. For the academic year that began in July 2002, there are about 8200 residency programs in the United States and about 100, 000 filled positions, including 21, 809 in internal medicine, 10, 178 in family practice, 7725 in pediatrics, 7257 in general surgery, and 4656 in obstetrics and gynecology, according to preliminary statistics from the ACGME. About 40 percent of residents are women. The mean salary is about $ 40, 000 a year, depending on the program and the year of training. The federal government, through the Medicare program, pays about $ 8 billion per year to train residents.
The increasing momentum behind limiting residents' work hours is a response to a variety of types of pressure, dating from the death of Libby Zion at New York Hospital in 1984. Zion's death focused attention on the hours and heavy workloads of residents and inadequate supervision by attending physicians. Since 1989, New York, where about 15 percent of physicians in the United States are trained, has had regulations that limit residents to 80 hours of work per week, averaged over a four-week period, and require round-the-clock supervision by attending physicians. There are 168 hours in a week. A resident who has overnight on-call duty every third night may work about 96 hours per week, and a resident who has on-call duty every fourth night may work about 84. 5 hours. Work hours can be reduced by decreasing the frequency of overnight on-call duty or the number of consecutive hours of work or by building rest periods into the schedule such as relief by a "night float" resident or a physician's assistant.
A resident who has overnight on-call duty every fourth night and a maximum of 30 consecutive hours of work may work about 77. 5 hours per week. The allowable numbers of continuous-duty hours for physician trainees are greater than those in commercial aviation, commercial driving, and the nuclear power industry. Limiting the number of work hours may protect the physical and mental health of residents, help them maintain a balance between their personal and professional lives, and facilitate learning. Long work hours have been implicated in motor vehicle crashes and complications of pregnancy and may have negative psychological effects. The Public Citizen Health Research Group, the Committee of Interns and Residents, the American Medical Student Association, and others petitioned the Occupational Safety and Health Administration (OSHA) in April 2001 to establish and enforce a federal work standard of a maximum of 80 hours a week, with no averaging among weeks. Sleep loss and fatigue may also cause harmful medical errors.
Although the widely publicized Institute of Medicine report entitled To Err Is Human focused attention on patient safety, it had little to say about physicians' work hours. Elsewhere in this issue of the Journal, Gaba and Howard summarize data about fatigue among clinicians and the safety of patients. Although it is difficult to prove that sleep deprivation impairs clinical performance, they conclude that most relevant studies do show impairment. Physicians must care for patients when they need care, regardless of the time of day or the convenience or inconvenience to the clinician. Their responsibilities often do not end when they leave the hospital. Despite the belief that better-rested physicians will provide better care, shorter working hours could have deleterious effects.
There is less continuity when the caregivers for a given patient change frequently. Each handoff creates opportunities for miscommunication, delays in providing care, and mistakes. A study of the effect of the 1989 New York State regulation that restricted the working hours for residents found that the restrictions were associated with delayed ordering of tests and increased rates of in-hospital complications. Another study found that the occurrence of potentially preventable adverse events was strongly associated with coverage by a physician from another house-staff team, which may reflect management of cases by residents who are unfamiliar with the patients.
A counterargument is that the additional physicians may discover problems or make diagnoses that would otherwise have been missed. When physicians spend fewer hours with their patients, it is more difficult for them to observe and respond to changes in their patients' conditions. Residents may also perform fewer operations or procedures. Although there are no data demonstrating that an 80 -hour workweek for residents is optimal, it has emerged as the standard. According to the Council on Medical Education of the American Medical Association, scheduled work hours should be limited o avoid accumulating a sleep debt that leads to deterioration in performance. The council claims that most adults should average eight hours of sleep per night or 56 hours of sleep per week.
To control for fatigue, most individuals should have at least five hours of sleep to work beyond 24 consecutive hours. To receive and maintain accreditation, residency programs must comply with common requirements and the standards for their specialty. The sponsoring institution must comply with institutional requirements. Each year, the ACGME, in conjunction with its residency-review committees, conducts about 2100 site visits of programs, according to Dr. David C.
Leach, the council's executive director. Each accredited program is visited an average of once every 3. 7 years, and the maximal time between visits is 5 years. If a program loses its accreditation, it will lose its residents; to be eligible to take board examinations, residents must complete an accredited program. After the ACGME conducts site visits of programs, it takes "adverse actions" against about 8 percent. Adverse actions include probation, a formal warning, and withdrawal of accreditation. Of 99 general-surgery programs reviewed by the ACGME in 2001, 18. 2 percent were cited for violations of duty-hour and related requirements, according to council statistics.
Citation rates were 21 percent for thoracic-surgery programs (19 programs reviewed), 18. 5 percent for internal-medicine programs (81 programs reviewed), 11. 4 percent for pediatrics programs (35 programs reviewed), 9. 6 percent for family-practice programs (136 programs reviewed), and 5 percent for obstetrics and gynecology programs (81 programs reviewed). Among institutions that sponsor training programs, the rate of adverse actions is higher about 30 percent. However, since the ACGME began conducting institutional reviews about a decade ago, no institutions have lost their accreditation. Although the council does not publicize adverse actions or make public the specific reasons for them, the accreditation status of each program is listed on the ACGME Web site. Programs must inform current residents and applicants about adverse actions.
The ACGME conducts follow-up site visits to determine whether the problems have been resolved. The ACGME currently has work-hour requirements that apply to all specialties. Residents must have at least one full day out of seven free of activities involved in patient care and must not be assigned on-call duty more often than every third night, both averaged over a four-week period. Otherwise, the standards vary widely among specialties.
Five specialties (allergy and immunology, dermatology, internal medicine, ophthalmology, and preventive medicine) have a weekly limit of 80 hours of work, averaged over a four-week period. Emergency medicine limits weekly hours to 72, of which only 60 hours may be spent in patient care. The requirements for general surgery give the program director the responsibility of ensuring the assignment of appropriate in-hospital duty hours. They claim, in part, that graduate education in surgery requires a commitment to continuity of patient care. This continuity of care must take precedence without regard to the time of day, day of the week, number of hours already worked, or on-call schedules.
After a site visit in July 2001, the ACGME withdrew the accreditation of the general-surgery residency program at Yale New Haven Medical Center, effective June 30, 2003, because of excessive work hours. For some rotations, residents routinely worked more than 100 hours per week; for others, they were on call every other night or did not regularly have one day off out of every seven, according to Dr. Peter Herbert, the senior vice-president for medical affairs at the medical center. In response, Yale has made extensive changes, including hiring physician's assistants to work on many surgical teams. The ACGME conducted a follow-up review in August 2002 and will decide whether to restore Yale's accreditation. Until recently, New York State, which has 115 teaching hospitals and about 15, 000 residents, has not vigorously enforced its work-hour limits.
In 1998, the New York Department of Health conducted simultaneous, unannounced surveys at 12 teaching hospitals. 9 After calculating working hours for 391 residents, it found that 37 percent worked more hours than the regulatory limits allowed; 77 percent of surgical residents in New York City and 32 percent of surgical residents in other parts of the state worked in excess of 95 hours per week. Four hospitals were fined up to $ 20, 000 each. The New York Department of Health conducted intensive educational programs about the work-hour requirements. The state increased the maximal fines to $ 6, 000 per violation for a first offense, $ 25, 000 for a second offense, and $ 50, 000 for a third offense and funded a surveillance program. 31 Of the 82 teaching hospitals inspected between November 2001 and June 2002, 54 were cited for violations. One was fined for recurring violations. The enhanced scrutiny in New York State has captured everyone's attention, but achieving full compliance has been a rocky road for many hospitals, according to Tim Johnson, the director of health finance and physician policy for the Greater New York Hospital Association.
One reason is that compliance is an all-or-nothing proposition; 92 or 95 percent compliance is technically noncompliance. A hospital does not get credit for being mostly in compliance. Many hospitals have responded by hiring more physician's assistants and other professionals. The number of registered physician's assistants in New York increased by 62 percent over a five-year period from 3893 in 1997 to 6294 in 2002. The limits on hours have met with skepticism as well as enthusiasm. According to the ACGME Work Group on Resident Duty Hours and the Learning Environment, the only way residency programs and their sponsoring institutions can achieve a true 'education' program, as well as provide high quality clinical care, is by attending to the issue of resident duty hours and by placing a higher value on resident education and safe patient care than on meeting service demands.
Under the new common program requirements, residents will be limited to 80 hours of work per week, overnight on-call duty will be limited to no more than every third night, and residents will have one day of every seven free of responsibility for patient care, all averaged over a four-week period. There will be a 24 -hour limit for on-call duty with an added period of up to 6 hours for continuity and transfer of care, educational debriefing and didactic activities; no new patients may be accepted after 24 hours. Between periods when they are on duty, residents will have a minimal rest period of 10 hours. If they take calls from home and are called into the hospital, the time they spend in the hospital will count toward the weekly limit. Teaching hospitals have increased responsibility for monitoring work hours and for patient care support services such as starting intravenous lines, phlebotomy, and transport activities to reduce the time that residents spend on these routine activities. The ACGME is also strengthening its systems for enforcing the requirements, including conducting detailed surveys of residents before site visits occur.
In general, the council will reassess compliance within six months after citing a program for violation of duty hours and rapidly review the practices of institutions that do not make necessary changes. The standards have a notable exception. Individual programs may apply to the graduate medical education committee of their sponsoring institution "for an increase in the limit of up to 10 percent, if they can provide a sound educational rationale. " Such an increase, which could raise the limit to 88 hours per week, requires the approval of both the graduate medical education committee and the residency-review committee for the specialty. Initially, the ACGME proposed a second exception that would have permitted the exemption of an entire specialty and that could have raised the limit to 96 hours per week. In September 2002, after reviewing comments, the ACGME changed its mind. Although the new standards are substantially stronger than the current standards, they are weaker than similar proposals from the American Medical Association and the Association of American Medical Colleges, as well as proposals for federal regulations.
After work-hour limits went into effect in New York in 1989, the state provided hospitals with millions of dollars to cover the costs. According to the ACGME Work Group report, it would be disingenuous to understate the added costs of these changes, or the challenge that securing the added funds will present for many sponsoring institutions. The council, however, unlike states or the federal government, does not pay for the required changes. The immediate costs are a serious problem, particularly for hospitals that are already in financial difficulty.
As of September 2002, OSHA had not responded to the petition that it establish work-hour limits for residents. Pending legislation in Congress would set a federal work limit of 80 hours per week, with no averaging among weeks, with overnight on-call duty no more frequently than every third night and a maximum of 24 hours per shift, with additional time for "transfer of direct patient care. Hospitals would have to comply with these limits in order to participate in the Medicare program. Violators would also be subject to fines of up to $ 100, 000 for each training program. The government would conduct annual anonymous surveys of residents and make public the results for individual programs. Violations and compliance of hospitals and programs would be disclosed to the public and in an annual report to Congress.
People who reported suspected violations or cooperated with investigations would be provided with "whistle-blower protections. " Hospitals would receive additional funding to cover the costs associated with compliance. New Jersey may soon become the second state to regulate residents' work hours. In June, the state assembly passed a bill that would establish an 80 -hour workweek, averaged over a period of four weeks, for the state's approximately 2400 residents and sent it to the state senate. Bibliography: Report of the ACGME Work Group on Resident Duty Hours. Chicago: Accreditation Council for Graduate Medical Education, June 11, 2002.
Philibert I, Friedmann P, Williams WT. New requirements for resident duty hours. JAMA 2002; 288: 1112 - 1114. Graduate medical education. JAMA 2002; 288: 1151 - 1164. [Full Text] 2001 AAMC survey of house staff stipends, benefits and funding: November 2001 report. Washington, D.
C. : Association of American Medical Colleges Division of Health Care Affairs, 2001. Report of the New York State Ad Hoc Advisory Committee on Emergency Services: supervision and residents' working conditions. New York: New York State Department of Health, October 7, 1987. N. Y.
State Codes R. & Regs. 405. 4 (b) (6) (1989). Hoffman J. Jurors find shared blame in ' 84 death. New York Times. February 7, 1995: B 1. Resident assessment: compliance with working hour and supervision requirements.
New York: New York State Department of Health, May 18, 1998. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, D. C. : National Academy Press, 2000. Gurjala A, Lurie P, Harmony L, et al.
Petition to the Occupational Safety and Health Administration requesting that limits be placed on hours worked by medical residents. Washington, D. C. : Public Citizen, April 30, 2001. ACGME Work Group charged with addressing resident duty hours. Chicago: ACGME, November 2001. AAMC policy guidance on graduate medical education: assuring quality patient care and quality education.
Washington, D. C. : Association of American Medical Colleges, October 2001. Patient and Physician Safety and Protection Act of 2001, H. R. 3236 (introduced November 6, 2001). Patient and Physician Safety and Protection Act of 2002, S. 2614 (introduced June 12, 2002). AMA delegates approve limits on resident working hours.
Press release of the American Medical Association, Chicago, June 20, 2002. N. J. Assembly Bill 1852 (introduced February 21, 2002).
State Health Department cites 54 teaching hospitals for resident working hour violations. Press release of the New York State Department of Health, Albany, June 26, 2002. Statement of justification / impact for the final approval of common standards related to resident duty hours. Chicago: Accreditation Council for Graduate Medical Education, September 2002. Winter MB, Angola-Israel S. Sleep deprivation and clinical performance.
JAMA 2002; 287: 955 - 957. The ACGME's role in protecting education, patient safety and resident safety: ACGME's response to HR 3236 and similar calls for regulation to address resident hours. Chicago: Accreditation Council for Graduate Medical Education, November 2001.
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