Two months after a national accrediting agency announced new guidelines that limit work hours for medical residents, critics are denouncing the controversial proposals as ineffective and meaningless.
The Chicago-based Accreditation Council for Graduate Medical Education, which oversees about 7,800 residency programs at 1,500 hospitals nationwide, approved new guidelines in early June to restrict doctors-in-training to 80 hours of work per week, averaged over a full month.
The new policies, announced at about the same time Congress was considering tougher guidelines for the nation's 100,000 residents, now are being described as inadequate by a coalition of groups that include Ralph Nader's Washington-based Public Citizen and the American Medical Student Association in Reston, Va.
The criticism is meant to highlight key differences between the ACGME's proposals and the far more stringent guidelines contained in proposed federal legislation, and to help focus renewed attention on the continuing battle in Congress.
"We're putting our efforts behind federal legislation and intervention," said Eric Hodgson, president of the AMSA, which represents about 30,000 medical students and residents. "Until that happens, we will continue our work. (The ACGME's guidelines) have, in fact, strengthened our resolve that legislation is the right route."
Peter Lurie, M.D., deputy director of Public Citizen, a national advocacy group, called the ACGME's proposals "a last-gasp effort to stave off federal legislation," saying they are "plagued by loopholes, exemptions and secrecy." The new guidelines, he said, represent a small, insignificant step toward eliminating industrywide policies that often allow weary residents to work 120 hours or more per week, threatening the health of both the doctors-in-training and their patients.
"We don't think they're the right people to police this," said Lurie, who outlined his objections in a letter earlier this month to the ACGME. "If they were truly interested in policing it, rather than just staving off government action, they would have done something about it years ago."
The federal legislation has stalled in Congress and does not stand much chance of passage this year, Lurie acknowledged. Though he said his complaints probably will do little to change the ACGME's guidelines, Lurie vowed to renew the struggle in Congress next year along with medical students and other activists who seek strict workhour rules and tough enforcement.
Hodgson said he wrote a similar letter of complaint to the accrediting agency, claiming the new guidelines lack enforcement, provide far too many exemptions and do not punish violators through public disclosure. Public Citizen raised similar objections along with another member of the coalition, the New York-based Committee of Interns and Residents, a union organization that represents about 12,000 residents.
Hodgson and Lurie, saying the ACGME's guidelines fall far short of the provisions included in the pending legislative measures, agreed that only a federal law would provide true reform in a system riddled with routine abuses for decades.
"These guidelines don't do enough," Hodgson said. "The public pays $8 billion a year to fund residency programs. We think the public has the right to be assured they're being treated at a hospital that takes (these workhour issues) seriously."
David Leach, M.D., executive director of the ACGME, defended the guidelines as a major step in assuring residency programs are designed to train young doctors, not to provide cheap labor for teaching hospitals. Individual residency programs, he noted, have indicated it might cost $1 million or more to meet the new standards.
Leach said the ACGME and Congress have been working independently, on parallel tracks, to try to deal with similar issues involving underpaid, overworked residents who typically are paid about $36,000 per year, or about $10 per hour.
"There's no doubt that Congress and the ACGME recognized the same problem," Leach said. "Each of us acted as our capacities dictated: Congress proposed legislation and we proposed changes in the accreditation standards."
Leach said he solicited comments from outside observers and "welcomes all kinds of opinions" but doubted the guidelines, which take effect in July 2003, would be altered substantially. "We don't anticipate change," he said.
The ACGME's rules, which call for 80-hour workweeks, actually allow for 88-hour workweeks if the institution can provide a "sound educational rationale" for the extra duty. Those total hours are averaged over one month, meaning that scheduling three 70-hour work weeks can later lead to a workweek that expands to 110 hours. Moreover, critics said, there is no public disclosure of hospitals that violate the rules.
By contrast, the proposed federal legislation would strictly limit workweeks to 80 hours, with no averaging. It would also impose civil penalties and provide for the public disclosure of hospitals that fail to follow the law. Public Citizen and the AMSA included those tough provisions in a petition filed last April with the federal Occupational Safety and Health Administration, which has yet to take action on it.