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Under pressure, medicine revisits resident work hours

From the March ACP-ASIM Observer, copyright 2002 by the American College of Physicians-American Society of Internal Medicine.

By Jason van Steenburgh

In a bid to make sure that new regulations aren't placed on residency training programs, educators are taking a new look at an old issue: housestaff work hours.

The issue of resident work hours first caught the public eye in 1984 when a patient died in the care of a tired resident in a New York teaching hospital. In 1989, after public outcry, New York set limits on the number of hours that housestaff can work.

Now, more than a decade later, resident work hours are again in the spotlight. This time, however, the issue has caught the attention of federal policy-makers and legislators.

Work Hours Rep. John Conyers Jr. (D-Mich.) has sponsored a bill that would give HHS the authority to regulate resident work hours. The bill, which mirrors the regulations New York put in place, would not let residents work more than 80 hours a week or more than 24 consecutive hours in a single shift.

In his bill, Rep. Conyers focuses on the errors that can take place when overworked and under-rested residents care for patients. He cites research showing that well-rested housestaff outperform sleep-deprived colleagues in tasks like interpreting ECGs and monitoring anesthesia.

Work hours as a policy issue

Politicians aren't the only ones examining residents' work hours. In its 1999 report on medical errors, the Institute of Medicine (IOM) wrote about the need to examine work hours "and their relationship to fatigue, alertness and sleep deprivation." The report is often credited with breathing new life into the issue of resident work hours.

At about the same time the IOM was preparing its report, the federal government reached a landmark decision on another question: Is residency training education or employment?

In 1999, the National Labor Relations Board (NLRB) reversed a longstanding verdict and said that residents are essentially employees, not students. Previously, only housestaff working at public hospitals in certain states were guaranteed the right to form unions. The NLRB decision paved the way for residents in private institutions throughout the country to unionize. It also led organizations representing residents—and in some cases medical students—to negotiate with hospital administrators about working conditions.

In April 2001, some of these same organizations petitioned the Occupational Safety and Health Administration (OSHA) to regulate their work hours as a workplace safety issue. They argued that because housestaff work excessively long hours, they run a higher risk of car accidents, depression and obstetric complications.

OSHA eventually declined to treat housestaff work hours in terms of workplace safety, but the issue had already caught the attention of medical educators. Last fall, the Accreditation Council on Graduate Medical Education (ACGME), which accredits and regulates residency programs, formed a workgroup to "review and refine" its policy on resident work hours.

The Association of American Medical Colleges (AAMC) weighed in on the issue late last year with guidelines calling for work hour limits. In its first-ever position on the issue, the group said that residents should work no more than 80 hours a week and no more than 24 hours consecutively. The guidelines, like many of the proposals to reform work hours, reflect key elements of New York's regulations.

Educators, however, adamantly oppose the call for more limits. They are quick to point out that the profession already regulates resident work hours, and that internal medicine is one of the few specialties that has very specific guidelines to do so.

The ACGME, for example, regulates each specialty's programs with a separate residency review council (RRC). The internal medicine RRC has created guidelines that say residents cannot work more than an average of 80 hours per week. Internal medicine rules also call for residents to have at least one out of every seven days free of patient duties over four weeks.

ACGME officials explained that they review all training programs at least once every five years. Programs that are cited for work hour problems must submit a progress report to the RRC before its next meeting describing how the problem has been remedied.

Robert E. Wright, FACP, who is program director for Scranton-Temple's residency program in Scranton, Pa., and serves on internal medicine's RRC, said his group takes work hour violations very seriously. He explained that the RRC has responded to resident complaints and media reports about work hour violations by notifying programs of the RRC's intent to put them on probation for violating guidelines.

Critics, however, say that work hour problems persist. According to data published on the ACGME's Web site, the internal medicine RRC cited roughly one-third of the internal medicine programs it reviewed in 1999 for violating work hours and related requirements. In 2000, it cited about 10% of the programs it reviewed.

Shift length

Some residents say that an 80-hour work week won't solve many of their problems. Chad Warren, MD, an orthopedic surgery resident at the University of California, Irvine, said the bigger problem is that individual shifts are just too long. "When you're between your 24th and 36th hour in a row," he explained, "you're not exactly learning very much. You're just trying to get through your day without making a serious mistake."

To get direct input from residents, the College's Council of Associates is surveying residents about whether training programs are enforcing work hour rules and whether federal regulation would help improve their work hours. The Council may use the survey's results to draft a policy on the issue.

Groups like the American Medical Student Association (AMSA) and the Council of Interns and Residents, a housestaff union, say they already know what residents want. Both groups support the 24-hour shift limit that the Conyers bill calls for.

Educators and program directors, however, fiercely oppose the idea of limiting residents' shifts. Not one of the ACGME residency review councils—not even internal medicine—has issued specific guidelines that limit shift length. In part, that's because of the logistical nightmares such a rule would produce.

R. "Hal" Baker, FACP, associate program director at York Hospital in York, Pa., explained that 24-hour shift limits would force attending physicians to serve as the bridge between different groups of residents. Attendings would have to gather patient information from residents at the end of their shifts, then hand off the patients to residents beginning the next shift. This handoff process could add several hours to attending physicians' schedules.

"There is a very big difference between a 24- and even a 26-hour rule," Dr. Baker said. Even a two-hour overlap in which both groups are in the same place at the same time would vastly simplify the hand-off process.

Dr. Wright added that the ACGME does not want residents to adopt a shift-worker mentality where they stop working as soon as they reach an RRC-mandated hour limit, regardless of patient status or how informed the other physicians are of that status. (Under Rep. Conyers' bill, residents nearing the end of their shift would not be allowed to accept a new patient.)

"We have to lift medicine out of the realm of the time clock," said Marvin Dunn, MD, ACGME's director of RRC activities. "Shifts cannot stop abruptly. There has to be sufficient transition time."

Dr. Dunn noted that many European hospitals with shift limits have found that significant errors are made during end-of-shift hand-offs. "We don't want that to happen here," he said.

Weekly averages

David L. Battinelli, ACP-ASIM Member, president of the Association of Program Directors in Internal Medicine, said the 80-hour work week and the 24-hour shift limits proposed in the Conyers bill would also give training programs less scheduling flexibility.

Under current guidelines from the internal medicine RRC, for example, residency programs can average housestaff work hours over four weeks. Residents can work 85 hours per week over three weeks, then work a 65-hour week, and the program is still in compliance. Averaging hours also allows residents to work two 28-hour shifts and balance their workload with a 16-hour shift.

Under proposals that don't allow programs to average resident work hours over several weeks, however, program directors would lose that flexibility. Residents would not be allowed to work more than 80 hours in a calendar week, which educators say would strip them of scheduling flexibility in the event of a widespread emergency or other extenuating circumstances.

Dr. Battinelli pointed to an even more puzzling issue in the debate over housestaff work hours: How do you define a work hour?

If a resident sleeps in an out-of-the-way hospital bed for five hours, for example, do those hours count as time on duty? If residents are rested and revitalized, he said, a 30-hour shift becomes much more manageable. "Someone needs to be very clear about the definitions of work and rest," he added.

Fearing regulation

As Dr. Battinelli was quick to point out, however, program directors aren't calling for clarification of these terms. They fear that in-hospital rest time could be included in a definition of duty hours, giving program directors even less latitude in scheduling housestaff.

That general loathing of outside regulation pervades medicine. Even organizations like the AAMC, which supports many of the ideas in the Conyers bill, oppose its passage into law.

And program directors like York's Dr. Baker, who stress that residents can't learn in a state of exhaustion, worry that government regulations would have unintended consequences for programs that are already placing educational interest above service. "Strict government regulation would be responding only to concerns about outliers," he said.

Government regulation wouldn't be popular, but a vocal minority views it as the answer. "Any time you ask the government to regulate an industry, people in the industry aren't going to be happy," acknowledged Robert Levy, director of legislative affairs for AMSA, one of a handful of medical groups that supports the Conyers legislation. "But we believe something outside the medical community has to happen on the resident work hour front."

Bob Dickler, vice president of the division of health care affairs at AAMC, said that the ACGME and its RRCs are the most logical venue to address the work hours issue. While he said the RRCs have worked to enforce the current work hour guidelines, he admitted that many think the guidelines themselves are not rigid enough and that the medical community hasn't gone far or fast enough to develop better ones.

Nevertheless, he is optimistic that medicine can get the job done without help from legislators. He compared the 1999 IOM publication on patient safety to reports on unacceptably high risks of anesthesiology in the United States. Those reports, he noted, successfully led that discipline to adopt more stringent safety requirements.

For now, it looks like educators will get more time to come up with their own plan. Policy analysts say the Conyers bill will not likely pass this year.

And later this month, the ACGME will release its work group's recommendations. Residents and their program directors will be waiting to see if—and when—the group chooses to implement them.

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