The IOM report calls for a maximum 80-hour week averaged over four weeks, limiting shifts to 16-consecutive hours, giving residents at least one day off a week and five days off per month, and counting residents' moonlighting toward their allowed 80 hours. Currently, the ACGME allows 24-hour continuous shifts with an additional six hours permitted for “continuity of care and educational activities.”
Sidney Wolfe, M.D., director of the Public Citizen consumer advocacy organization's health group, notes how “few, if any, people would fly on a plane whose pilot had been awake and working for 25 to 30 hours.” He added that if the federal government regulates the number of consecutive hours a pilot or truck driver can work, why not do the same for doctors?
At a teleconference, Wolfe and others announced a new Web site, wakeupdoctor.org. It contains a petition addressed to Thomas Nasca, M.D., ACGME executive director, and Rep. Henry Waxman (D-Calif.), chairman of the House Energy and Commerce Committee, and signed by some 48 national and regional patient-safety and consumer advocacy groups.
“Given press reports over the past year highlighting the academic medical community's criticisms of the IOM recommendations … we are fearful that the ACGME will choose not to adequately act on the evidence at this critical juncture,” the letter states. “It is our belief that the ACGME's commitment to quality patient care and resident education should, at a minimum, result in prompt adoption of the IOM recommendations.”
Charles Czeisler, M.D., director of the division of sleep medicine at Harvard Medical School, says there is “widespread falsification” in work-hour reporting. ACGME spokeswoman Julie Jacob, however, tells Modern Physician that every complaint it receives about noncompliance with work-hour limits is investigated.
The ACGME board could have released a proposed revision of its duty-hour regulations for public comment at its meeting in Scottsdale, but that didn't happen, and Jacob says Nasca doesn't want to attach a firm timetable to any revisions it might release. The board will meet via teleconference in June, Jacob says. If it decides to release revisions for public comment at that time, the board could vote on new rules at a tentatively scheduled Sept. 27-28 meeting with implementation coming in July 2011 at the earliest, Jacob says.
It has been estimated that implementing the work limits recommended by the IOM could cost the U.S. healthcare system up to $1.7 billion, but Czeisler says a cost-benefit analysis showed this could be offset with only a 10% reduction in fatigue-related errors. That is based on the premise that each mistake resulted in an additional $5,000 to $6,000 in costs.
Czeisler compares the impairment caused by working 24 hours without sleep with the impairment caused by drinking alcohol. He cites a study that found residents working 30-hour shifts in an intensive-care unit made 460% more diagnostic mistakes than those scheduled to work 16-hour shifts.
Critics also suggest that hospitals use residents as a source of cheap labor to perform nonphysician tasks such as drawing blood or transporting patients.
But Joanne Conroy, M.D., chief healthcare officer for the Association of American Medical Colleges, disagrees. “As an anesthesiology resident, I did a lot of nursing work and that made me a better doctor,” Conroy says. “I had no qualms about changing a bedpan or getting people water because it brings you closer to the patient.”
The idea that residents were a source of cheap labor may have been common 15 years ago, Conroy says, but now hospitals realize that most residents wind up practicing near or at the facility they trained in, and it's in hospitals' best interests to provide the best educational experience possible.
“Just limiting hours is not going to eliminate fatigue,” Conroy says, adding that properly managing the hand-off of patients between residents changing shifts may do more to reduce errors.
Helen Haskell, who founded the organization Mothers Against Medical Error, says resident fatigue played a role in the death of her 15-year-old son Lewis' death after surgery at the Medical University of South Carolina at Charleston in 2000.
“This system has been structured like this for a real long time and people have structured their financial interests around it, and it would be a big deal to change it,” Haskell says. “But, to deny that this is a patient-safety issue is to have your head in the sand.”
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