Proposed Duty Hour Limits for Residents Met with Scrutiny

Resident Physician: Take a nap. Limit your hours.

Sounds good, no? The decades long-debate over how long resident physicians should keep working per shift, and how much rest they need, continues, like a long-running dream. These are major questions being considered by medical directors of residency programs as new regulations come online in July.

The Accreditation Council for Graduate Medical Education (ACGME) is preparing to launch regulations that say first-year physician residents must work no longer than 16 consecutive hours. The plan includes provisions to replace standards that now allow interns to work 24 consecutive hours.

The ACGME, which is promulgating the regulations, is a non-profit organization that oversees training programs for resident physicians and is responsible for regulating and enforcing resident physician work hours, and accreditation of post-MD medical training programs.

While the ACGME insists it has made inroads into the fatigue issue and related patient safety concerns, physician residency program directors suggest in a new survey they aren't exactly pleased with the plan. I don't think it will do much to allay their concerns about physician exhaustion and patient care.

Residency program directors' reactions to the ACGME duty hour recommendations "demonstrate a marked degree of concern" about physician education, according to the study by Darcy A. Reed, MD, MPH, Division of Primary Care Internal Medicine for the Mayo Clinic, and her co-authors, reported in the March issue of Mayo Clinic Proceedings. The Mayo Clinic was not associated with the survey, which was conducted after the ACGME published its recommendations.

The survey results, according to the researchers, "suggest that the new duty hour restrictions have the potential to create serious difficulties for residency programs to ensure that their trainees are meting the ACGME core competencies."

The new regulations include increased supervision during 16-hour shift maximum for first year postgraduate residents and recommendations for napping.

In the survey of resident medical directors, there was an outpouring of disagreement with the ACGME duty-hours regulations. Among the findings:

• 65% say it will not change resident fatigue.
• 6% believe it will increase fatigue.
• 87% say that the new ACGME recommendations will decrease residents' continuity with hospitalized patients, referring to "hand-offs" during shift changes.
• 78% say it will reduce efforts to coordinate patient care.
• 65% believe it will reduce residents' responsiveness to patient needs.
• 63% believe it would reduce residents' ability to effectively communicate with patients, families and other health care professionals.

Reed says it was important to question the resident medical directors about the impending regulations because "they are the ones who know what it takes to train a competent resident."

"That's why we sought their opinions," Reed says. "Some things we need to watch out for and be mindful of as the new regulations are put into place. The research isn't going to change the recommendations. That wasn't the intent. We are trying to get a sense of what program directors feel about this."

Obviously, she says, there is concern about the regulations and the impact on residents' fatigue.

Although there are new restrictions about work hours, "we don't know that the residents will necessarily sleep in the hours they aren't working," Reed says. "We assume if they are working fewer hours, they will recuperate and rest, and sleep. But that may not be. There are a lot of other factors involved: family life, level of stress, and many other activities they may be engaged in."

In addition, resident medical directors apparently are concerned that residents may simply work more over a shorter period of time, which could have a dramatic impact on patients as well as the physicians themselves, Reed says. "That's a big concern. If they reduce their hours they just might compress the same amount of work into a shorter period of time," Reed says. "Maybe they will be asked to do the same stuff but do it faster."

Another major concern is "handing off a patient to another physician at the end of a shift," she says. "We know during the hand-off, that is a high risk event. It's a vulnerable time."

How to reduce the risk of an overly tired young physician has been a point of debate for years.In the 27 years since the death of a young woman who was under the care of an apparently exhausted physician in a New York hospital, various groups have debated how much physician time should be regulated.

After the tragedy, New York State initiated changes, and in 2003, the ACGME issued "duty hour" regulations, making them mandatory for all residency programs. The ACGME says the regulations resulted in a significant reduction nationwide in duty hours and fatigue among resident physicians.

This past December, the Institute of Medicine released a report recommending strict work-hour rules. The report, ResidentDuty Hours: Enhancing Sleep, Supervision, and Safety" stated that "30 hours of continuous time awake, as is permitted and common in current resident work schedules, can work in fatigue and adjustment to the 2003 rules are needed. The ACGME' then proposed revised standards.

Under the latest regulations being implemented, among other things, residents must have 10 hours off between duty shifts and must have eight hours free of work between duty hours.

Residents also must not be scheduled for more than six consecutive nights of night duty; have 24 hours off per 7-day period, with maximum duty hours of 80 per week, averaged over 4 weeks, with 88 hours for selected programs. Moonlighting is not permitted.

Last September, the advocacy group Public Citizen filed a petition with the Occupational Safety and Health Administration requesting that the agency regulate resident physician and subspecialty resident physician hours.

"Depending on the type of residency, physicians-in-training can work anywhere from 60 to 100 or more hours a week, sometimes without a day off for two weeks or more," the Public Citizen petition states.

Because OSHA, which is part of the Department of Labor, is charged with ensuring the safety and health of workers, it has jurisdiction over the matter, Public Citizen and other groups that joined in the petition say.

In 2002, OSHA denied a petition by Public Citizen, the Committee of Internists and Residents (CIR), and American Medical Student Association, citing the voluntary adoption of standards by ACGME. 

Referring to its current petition, Sidney Wolfe, MD, director of Public Citizen's Health Research Group, said in a statement, "The dangerously excessive number of hours resident physicians are currently allowed to work is a similarly toxic exposure that OSHA has the authority to regulate and reduce in order to protect these physicians from harm."

"This is especially urgent since the current private-sector regulating organization, ACGME, has continued to abdicate its responsibility to adequately protect resident physicians," Wolfe stated.

The ACGME opposes the petition, noting: "The interests of residents and patients are served by maintaining an approach that is comprehensive and that is designed to weigh and balance in an integrated manner the full spectrum of different interests and considerations applicable to graduate medical education."

"The ACGME does that now; and the petition, if granted, would seriously disrupt the effectiveness of that system by establishing regulation of resident duty hours within the exclusive purview of the OSHA," it adds.

The current debate can be traced to the death of Libby Zion in 1984, which prompted the New York legislation to adopt regulations regulating working conditions of physicians.

The 18-year-old college freshman was admitted to New York Hospital with a high fever and mysterious jerking movements, Barron H. Lerner, MD, wrote two years ago in the New York Times.

Lerner, who was a medical student at the time, wrote that the "only doctors who had seen her were in training, that such doctors routinely worked 36-hour shifts with little or no sleep and that the attending physicians had never come into the hospital." Zion's father worked feverishly for reform, stated Lerner, a professor of medicine and public health at Columbia University Medical Center, and author of "When Illness Goes Public: Celebrity Patients and How We Look at Medicine."

After Libby Zion's death, medical students looked into their own education, and themselves, as budding physicians, in a world of intensity, and exhaustion, as they tried to retrace her care, and what went wrong.

"Would we have ordered restraints and not seen her? Would we have sent her to the intensive care unit? Would we have known about a potentially toxic interaction between drugs in her body?

Ultimately, they concluded there was a "for the grace of God go I," he wrote. "We knew what it was like to stay up for 36 hours straight, first as medical students and later as residents. It was in, a word, insanity."

In Reed's survey report, a mention was made of Libby Zion's death. It still looms large as the debate continues over physician "duty hours."