The Accreditation Council for Graduate Medical Education says its new hours-of-work standards, effective July 2003, limit residents to an 80-hour workweek.
But a closer look reveals loopholes allowing for much longer hours.
For example, the standards approved June 11 allow the sponsoring hospital of a residency program to raise the limit to 88 hours a week. And since that limit is averaged over a month, it could rise to 100 hours on any given week.
Furthermore, the limit can be removed altogether "in the case that a specialty believes it cannot conduct its educational activities within the proposed constraints," the standards read.
This exemption is "designed to accommodate in particular small programs like neurosurgery and thoracic surgery," says David Leach, M.D., executive director of the ACGME. "They often have just one or two residents, so it's going to take some unusual efforts to accommodate them."
But the layers of ACGME loopholes are prompting some critics to renew calls for state and federal legislation to set strict 80-hour limits. Such language is part of active bills in Congress and in the New Jersey Legislature.
The accreditation standards are "a big step for the ACGME, and we appreciate that," says Eric Scherzer, associate director of Committee of Interns and Residents, a residents union in New York City. "But there are a bunch of loopholes here, and there's a real question if they will be enforced."
In yet another loophole, the ACGME limits work shifts to 24 hours, then allows programs to add another six hours for a transition. Leach says surgery residents might need more time if they were called into an 18-hour emergency operation toward the end of their shift, and residents could also use the transition to attend lectures.
But Scherzer says six hours is too long and questions assisting in an operation or attending a lecture after 24 hours with no sleep.
The American Medical Student Association reports that after 24 hours of wakefulness, cognitive function deteriorates to a level equivalent to having a 0.10% blood-alcohol level, which equals or exceeds the drunk-driving limit in all 50 states.