Giving residents a break

Medical residents at teaching hospitals may still be working 80-hour weeks, but they'll be doing so with more supervision and more breaks, under revisions to the medical resident work-hour standards proposed by the Accreditation Council for Graduate Medical Education.

But the increased complexity of the new rules may also make it more difficult to document compliance, and many observers still feel that allowing senior residents to remain on duty for 24 consecutive hours defies common sense and puts patients at risk.

The main item in the proposed revisions, which were developed by an ACGME task force that first met in February 2009, is that the 80-hour workweek—averaged over four weeks—remains intact. The 80-hour cap was instituted in 2003, and a 2008 Institute of Medicine report on the subject recommended keeping it in place—but with more restrictions on consecutive hours and days worked coupled with mandatory days off and periods of uninterrupted sleep (Dec. 8, 2008, p. 6).

In addition, the ACGME proposal would require that first-year residents—also known as “interns”—work under the direct supervision of an attending physician or have access to an on-site physician to provide direct supervision if needed.

In a report posted on the New England Journal of Medicine website on June 23, the ACGME said its goal was “to foster a humanistic environment for graduate medical education that supports learning and the provision of excellent and safe patient care.”

The proposed revisions include a call to limit first-year residents to 16 consecutive work hours, and one medical school official said he believes this will help further the ACGME's goal. But another says it may also have some hospitals scrambling to provide coverage and continuity of care as senior residents would still be allowed to stay for 24 hours of continuous duty. “In a nutshell, these changes are positive, and they are important for patient safety and important for resident education,” said Saul Weiner, interim senior associate dean of academic and education affairs at the University of Illinois College of Medicine and an associate professor of medicine and pediatrics at the University of Illinois at Chicago. “These revisions call for a greater degree of humaneness and more respect for residents as people. When you treat residents badly, they are more likely to treat patients badly.”

Weiner said that when he was a resident some 16 years ago he worked 110 to 115 hours a week and when he walked in, he had no idea when he would walk out. “There were times when you never sat down,” he said. “It almost became a question of survival, and the survival mechanism we used was to tell ourselves: ‘Real doctors don't need sleep.' ”

But ACGME board member Carol Rumack, a professor of radiology and pediatrics and the associate dean for graduate medical education at the University of Colorado at Denver School of Medicine, predicts that there will be problems because the first-year residents may not be around during critical periods when their senior colleagues change shifts and pass along vital patient information. “I think the intern is going to miss that overlap and knowledge exchange,” Rumack said. “If you were on an assembly line, that would be fine, but patients are not equipment.”

The ACGME's New England Journal report touched upon this subject and noted how the duty-hour limits can create a “shift mentality” among residents that leaves them unprepared for the unpredictable nature of a physician's professional obligations.

Rumack's main criticism of the proposed revisions is that the new limits on consecutive hours and mandated time off appear to be “partly driven by sleep experts.”

John Brockman, president of the American Medical Student Association, disagreed and said his organization believes the 16-consecutive-hour cap should apply to all residents. He noted that research shows that “function drops off markedly” after 16 hours and that the “strategic napping” the ACGME recommends after 16 hours is not effective.

Brockman agreed with the Public Citizen consumer advocacy group's criticism that allowing senior residents to continue to work 24-hour shifts defies common sense and ignores “ample evidence” that marathon shifts can impair physician performance. “It's a little bewildering to us why they didn't extend those protections to all patients and residents on all shifts,” he said, though he added that the proposed revisions were a step in the right direction. “This is leading to a cultural change in medicine,” Brockman said. “It's important that we change from ‘work until you drop' to doing what's in the patients' best interests.”

Public Citizen also echoed the IOM's 2008 report's criticism of the ACGME's enforcement of work-hour limits, but Weiner said he has been impressed with the effort to step up oversight—although he wonders if the ACGME will be able to maintain the same level of enforcement under the new rules. “I will say it's going to be pretty complicated to monitor” because the proposed rules are more complex, Weiner said. “Before, there were a handful of rules of thumb that were pretty easy to follow.”

The ACGME will be taking public comments on its proposals until Aug. 9, and its task force “will consider all comments and make modifications if needed,” the New England Journal report stated, with new standards taking effect in July 2011.

The IOM estimated that the changes it recommended could cost teaching hospitals up to $1.7 billion while a subsequent RAND Corp. study estimated that the cost would be between $1.6 billion to $2.5 billion depending on who supplies the substitute labor.