Sleeping in order

Any thought of relaxing the 5-year-old rules that limit medical-resident duty hours was put to rest last week by an Institute of Medicine report that called for even stricter limits on how hard to work residents at teaching hospitals. The IOM says tougher limits would result in more alert and better-trained physicians. But critics say implementing the IOM’s recommendations would raise costs and put more patients at risk for poor or unsafe care.

Not only did an IOM report released last week call for maintaining Accreditation Council for Graduate Medical Education, or ACGME, rules that limit medical resident duty hours, it said the rule needed to be better enforced—even declaring that “the status quo is unacceptable”—and that residents needed defined periods of sleep and increased opportunities for “catch-up” sleep, and that stricter limits be put on resident “moonlighting” jobs.

In its new report, Resident Duty Hours: Enhancing Sleep, Supervision and Safety, the IOM calls for a maximum 80-hour week averaged over four weeks, limiting shifts for the most part to 16-consecutive hours, giving residents at least one day off a week and five days off per month, and counting residents’ outside moonlighting toward their allowed 80 hours. The increased labor costs associated with these limits were estimated at $1.7 billion.

Implementing the IOM’s suggestions would mean additional changes to rules instituted in 2003 by the ACGME. Those rules call for internal moonlighting jobs to be included in a resident’s 80-hour count (allowing external moonlighting); allowed for 30-hour shifts divided between 24 hours of admitting patients and six hours of educational and transitional activities; didn’t limit the frequency of night shifts; and called for 10 hours off after any shift while the new report recommends 12 hours off after a night shift and 14 hours off after any extended 30-hour period. (The new recommendations allow for a 30-hour shift if five hours of sleep are provided after 16 hours of work.)

The report from the IOM follows congressional interest in the matter. The report was funded by the Agency for Healthcare Research and Quality at the request of the U.S. House of Representatives’ Energy and Commerce Committee. In a March 29, 2007 letter, Rep. John Dingell (D-Mich.) and other committee members wrote a letter to the AHRQ that cited a December 2006 study on the impact of extended duration shifts on medical errors and a 2004 IOM report on the work hours of nurses, and then asked the AHRQ to “assist us in ascertaining if the long work hours of physicians and residents also are among the most serious threats to patient safety.”

The IOM says that in order for the new plan to work, team training will have to be enhanced to allow for safer handoffs; noneducational “scut work,” which sources said includes drawing blood or paperwork and scheduling duties traditionally done by residents will have to be handled by someone else; and the ACGME will have to take on a more-regulatory focus.

The IOM report was given a lukewarm reception from industry representatives for both hospitals and physicians who ask how the plan will be paid for and wonder if patient care would suffer—not improve. “If the current duty-hour limits are modified, it will be important to consider the impact of potential changes on other members of healthcare teams and the effect on patient care,” said Darrell Kirch, president and chief executive officer of the Association of American Medical Colleges, in a written statement. Kirch said that the industry is still trying to put changes from the ACGME 2003 standards into practice, with even more changes complicating matters further. “The planning and implementation of any further changes will require significant time and resources,” he said.

In a Modern Healthcare interview in October 2007, Kirch noted that it was important to be sensitive to issues concerning attention and fatigue, but there may be more to it than simply tracking residents’ work hours. “I think the core truth of duty hours is that now we are paying attention to that, and we’re trying to put systems into place,” Kirch said. “But I think the other thing that we’ve learned is that healthcare is such a complex environment, and different patients present different kinds of challenges that we’re going to have to have, perhaps, more flexibility than very rigid, formulaic controls on hours.”

The Health Research Group of the Public Citizen consumer advocacy group panned the report, stating that it “bends over backwards in its efforts to address the concerns of organized medicine and in so doing has forgone a golden opportunity to enhance patient safety.”

Despite the $1.7 billion price tag, IOM representatives are confident that funding can be found, given the important role that teaching hospitals play in healthcare. “The committee definitely recognizes that there are costs,” said David Dinges, a a University of Pennsylvania School of Medicine professor who served on the committee that wrote the report. “But there could be savings in the long run with improvements in patient safety—but that has not been proven.”

The report said that there are 105,000 residents training at the nation’s 1,206 teaching hospitals and gave two options for meeting the labor demands: Either add 8,247 new residency positions or hire the equivalent of an additional 5,984 “midlevel providers,” such as physician assistants or nurse practitioners, 5,001 attending physicians, 229 nursing aides and 45 laboratory technicians.

Dinges, who is also chief of UPenn’s Psychiatry Department’s sleep and chronobiology division, said the report was evidence-based and reflects the fact that there is more known about how much sleep people need than how much they should work. “We’re hoping the important issues don’t get lost in debates about cost and who should regulate,” he said.

Another member of the committee, Ann Rogers, an associate professor at the University of Pennsylvania School of Nursing, said the need to combat fatigue and ensure alertness is more critical than ever. “The workload has gotten much, much heavier,” she said.

Donald Girard, associate dean for graduate and continuing medical education at the Oregon Health & Science University’s School of Medicine, agreed with this assessment. “My colleagues out there are saying ‘These young people are lazy; this is the way we were taught.’ But when I was in training 40 years ago, we didn’t have an ICU, and patients were in the hospital for weeks at a time,” he said.

Also supporting the move was Toni Lewis, president of the Committee for Interns and Residents for the Service Employees International Union, who said: “What it comes down to is ‘Is it worth it?’ And yes, it is,” she said. The committee represents some 13,000 resident physicians.

Among those disputing the wisdom of a 16-hour shift limit was the American College of Surgeons. On March 4, the group released a position paper that called for exempting chief surgical residents from duty-hour limits “to allow a more realistic transition to a postgraduate career,” and said that restricting surgical resident work weeks to less than 80 hours “could result in deteriorating quality” and “could cause irrevocable damage to a surgical residency training system.”

In a written statement released last week, the American College of Surgeons applauded the IOM report for not recommending a reduction in the 80-hour weekly limit, but then also slammed it for its recommendation to limit shifts to 16 hours, declaring that this “could compromise the education of the residents and possibly affect the continuity of patient care.”

Carol Rumack, associate dean of medical education at the University of Colorado School of Medicine in Denver, agreed. “If someone needs a surgeon in the middle of the night, we don’t say ‘Sorry, there’s nobody here,’ ” Rumack said. “The IOM report may be an ideal, but what’s realistic in this economic downturn we’re in?” she asked. “It’s reasonable to say it will be a major expense to do everything in this report.”

Although the report allows for flexibility, Joanne Conroy, chief healthcare officer at the Association of American Medical Colleges, said flexibility and customization can create their own challenges—especially at larger institutions. “When you’re dealing with 500 residents, you wind up developing hard-and-fast rules because you find you can come up with exception after exception,” she said.

The IOM report committee called for implementation of its recommendations within two years, with one exception: making sure exhausted residents get home safely or provide them a place to sleep on-site. Susan Vanderberg-Dent, associate dean of GME at 676-bed Rush University Medical Center in Chicago agreed with the urgency of that situation—in part because of her own experience in an incident that occurred after arriving at the hospital at 7 a.m. and leaving the next day at 8 p.m. “I fell asleep and came to just as I was about to drive off the road—on the wrong side of the road,” she said.

The report also calls for strengthening the current monitoring process by increasing the frequency of hour-duty audits, which are currently done every three years, making unannounced site visits, and developing whistle-blower protection mechanisms. ACGME Chief Executive Officer Thomas Nasca said his organization was up to the task of oversight. “We couldn’t do it next week, but we could ramp up pretty quickly,” Nasca said.

And, while Nasca said he appreciated the IOM committee’s work, he added how residents have to be prepared for the physical aspects of the job. “Residency is not just education, it’s also training,” he said. “One does not become a marathon runner without a significant amount of practice and discomfort. Residency provides exposure to the physical rigors of being a physician—which are not insignificant.”