Resident Rules

When the federal government recently issued 10 "simple" patient-safety tips for hospitals, two suggestions addressed some of healthcare's hardest workers: residents who care for patients while getting their education.

• Limit shifts of more than 24 hours for medical residents.


• Eliminate the tradition of shifts of more than 30 consecutive hours by interns working in hospital ICUs.

Good ideas? Probably. Simple? Not so much.Because most residents do not punch time clocks, hospital administrators who employ them often have no real-time knowledge of the hours their residents are working. Responsibility for monitoring work hours lies with the institutional- and program-level directors of some 8,000 residency and fellowship programs in about 750 hospitals across the nation."You will probably get a different response from every institution in the way they handle this," says John R. Musich, M.D., vice president and director of medical education at Beaumont Hospital in Royal Oak, Mich. "There is no one right way to do it, and there are many effective ways to do it."In 2003, the Accreditation Council for Graduate Medical Education limited residents to 80 hours of duty per week on average and restricted shifts to 30 consecutive hours. Residency programs that violate the work-hour rules risk losing their accreditation. Musich supervises 34 accredited programs at Beaumont, each of which developed its own protocols for monitoring work hours. In some programs, residents log their work hours each week; in others, a spot check of work hours is conducted about one week each quarter. That is sufficient, he says, for the many programs in which duty hours do not come close to the 80-hour limit.But the truth about whether residents are generally complying with the restrictions is under heavy debate. The ACGME has consistently found that the vast majority of residents do; researchers at Harvard Medical School and Vanderbilt University Medical Center in 2006 published studies in the Journal of American Medical Association and the American Journal of Surgery, respectively, saying the vast majority are not. But while others bicker over research methodologies, hospital administrators should consider the costs of overwork. "From a patient care standpoint as well as a medical liability standpoint, I think CEOs should have grave concern," says Christopher P. Landrigan, M.D., M.P.H., director of the Sleep and Patient Safety Program at Brigham and Women's Hospital in Boston. Landrigan's research suggests that long work hours translate into safety problems for patients and residents alike. -Lola Butcher

---

What does the evidence say?

• When work-hour restrictions first went into effect, Robert O. Carpenter, M.D., M.P.H., a surgical resident at Vanderbilt University Medical Center, felt the stress of conflicting pressures. "You are supposed to follow these rules, and you have an ethical obligation to do that," he says. "But at the same time, there were a lot of attendings pressing you to work the old way, just look the other direction and write down the hours." Carpenter and several colleagues conducted a study that confirms that many residents are being put in an ethical dilemma between patient care and following the rules. Their finding: A significant number of residents feel compelled to exceed work-hour regulations and report those hours falsely.


• First-year interns working "traditional" long work weeks and 30-hour shifts in intensive care units made 36 percent more serious medical errors, including five times more serious diagnostic errors, than they did when work shifts and total work hours were reduced, according to a Harvard research team. They also found medical interns who work shifts of more than 24 hours are more than twice as likely to have a car crash leaving the hospital than their peers who work shorter shifts.

-Lola Butcher