Lax Rules for Medical Residents an 'Abuse of Trust'

NOTE:  New rules on medical residents' hours issued by The Accreditation Council for Graduate Medical Education became effective July 1, 2011.

A sweeping revamp of the rules that govern the nation's hospital residency programs is needed immediately to protect patients from the serious preventable errors that have been linked to the long working hours of exhausted physicians in training.

That's the message from a group of more than two dozen patient safety, medicine and research organizations, who are calling for the implementation of recommendations set forward in 2009 by the Institute of Medicine.

A white paper published in the current issue of the online journal Nature & Science of Sleepsays the rules for residency training set to take effect on July 1 "stop considerably short" of patient safety best practices. The report calls on hospital administrators and residency program directors to install additional safeguards.

"The current system amounts to an abuse of patient trust," Lucian Leape, MD, adjunct professor of health policy at the Harvard School of Public Health and a coauthor of the report, said in a media release. "Few people enter a hospital expecting that their care and safety are in the hands of someone who has been working a double-shift or more with no sleep. If they knew, and had a choice, the overwhelming majority would demand another doctor or leave."

The report examining residency work hours, supervision, and safety is the product of a conference at Harvard Medical School last year that was held to draw a road map for implementation of the IOM recommendations. Those recommendations included eliminating shifts exceeding 16 hours without sleep for all resident physicians. The recommendations have yet to be implemented.

Starting July 1 the Accreditation Council for Graduate Medical Education will limit the shifts of first-year residents to no more than 16 hours without sleep. However, ACGME will continue to permit shifts of 28 consecutive hours for more senior residents, including surgical residents.

The ACGME's pace for implementation of the IOM recommendations was singled out for criticism in the report, and by the advocacy groups. Charles Czeisler, MD, a coauthor of the report and chief of the Division of Sleep Medicine at Brigham and Women's Hospital, in Boston said the ACGME has taken a "very limited" approach to the IOM's recommendations, noting that the ACGME's new rules will cover only "a small fraction" of the resident workforce and not get at the root of the problem.

"Extensive research has shown that experience does not overcome the need for sleep," Czeisler said in a media release. "There is no justification for maintaining unsafe work hours, other than that they're a good deal for hospitals. But they endanger patients, and they even endanger residents."

Czeisler said ACGME enforcement was insufficient because it relies on self-regulation, and lacks external or public accountability.

Attempts to obtain comments from ACGME were unsuccessful.

Christopher Landrigan, MD, a co-author of the Harvard report and lead author of the North Carolina Patient Safety Study, says rates of harm due to medical error have been constant. "Adoption of even the best proven interventions to reduce medical errors – including elimination of shifts exceeding 16 consecutive hours for resident physicians – has been extremely poor," he said.

The Harvard recommendations cover six other areas: workload and supervision; moonlighting; resident physician safety; hand-over practices and training in quality improvement; monitoring and oversight of the ACGME; and funding for reform implementation.

Key recommendations include:

• Limiting all resident work hours to shifts of 12 to 16 hours;
• Making ACGME work-hour compliance a condition of participation for Medicare graduate medical education support.
• Identifying in real time when a resident physician's workload is excessive and additional staff should be activated;
• Requiring attending physicians to supervise all admissions;
• Mandating in-house supervision for all critical care services, including emergency, intensive care and trauma services;
• Making fatigue management a Joint Commission National Patient Safety Goal. The recommendations note that "fatigue is a safety concern not only for resident physicians, but for nurses, attending physicians and other healthcare workers."
• Redesign resident workload requirements to maximize educational value. Much of what residents currently do – drawing blood, filling out paperwork and starting intravenous lines adds to their heavy workload and is more appropriately done by other hospital personnel.
• Provide transportation to all residents who are too tired to drive home. In addition, hospitals should provide transportation for all residents who, for unforeseen reasons or emergencies, work consecutively for more than 24 hours.
• Include moonlighting in work hour limits. Hospitals should establish formal policies on moonlighting and actively monitor resident physician moonlighting.

Medicare pays more than $9 billion a year to academic medical centers, which is used to cover residents' salaries. The report's authors said that re-designing training to eliminate dangerously long shifts, waste and inefficiency will produce savings that will help to offset the cost of hiring additional personnel if they are needed.

See Also:
Do Sleepy Medical Residents Jeopardize Patient Care?
10 Ways to Improve Handoffs in Your Hospital