UO > Policy Points > Working Hours

schedules, but the pending loss of accreditation, of course, got their attention and the process of complying with ACGME standards was expedited. Four months after the notice of potential loss of accreditation, ACGME renewed accreditation of Johns Hopkins’ internal medicine program for three more years.

Johns Hopkins is not the only training program to receive discipline from ACGME. The Martin Luther King Jr./Drew Medical Center in Los Angeles had its general surgery program placed on probation in 2002, and then lost accreditation altogether in 2003 for, among other reasons, exceeding the number of hours that residents are allowed to work. In addition, from July 2003 to July 2004, ACGME, which accredits more than 7,900 residency programs, issued 108 citations for failure to comply with working-hour requirements.

The Council’s standards for working hours for residents took effect in July 2003. They are part of ACGME’s “Common Program Requirements,” available on line at www.acgme.org

• Duty hours are limited to 80 hours per week, averaged over a four-week period. Duty hours encompass clinical and academic activities, including administrative duties relative to patient care, transfer of patient care, time spent in-house during call activities, and conferences. Duty hours do not include off-site reading and preparation time.

• Residents must be given one continuous 24-hour period free from all duties each week, averaged over a four-week period.

• Residents should be given 10-hour rest periods between daily duties and after
in-house call. (This requirement is stated
as a “should” rather than a “must.”)

• “In-house call must occur no more frequently than every third night, averaged over a four-week period.”

• “Continuous on-site-duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to 6 additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care.”

• “No new patients may be accepted after 24 hours of continuous duty.”

ACGME allows individual residency programs to request “exceptions” from the 80-hour-per week limit, up to a maximum of a 10 percent increase (eight additional hours). ACGME also allows specialty programs to vary or supplement the “Common Program Requirements.” For example, the pediatric specialty requirements provides that “It should be noted that the intent of the six-hour post-call period is primarily for concluding continuity of care activities for those patients who were cared for while on-call.... Post-call residents may not attend other clinics, such as a subspecialty clinic.” The “Duty Specific Duty Hours” are available on line at www.acgme.org

The American Medical Student Association (AMSA) believes that the ACGME requirements are an improvement over prior practice, but also believes that the ACGME requirements do not go far enough. From the association’s view, there are several “loopholes” that should be closed. Instead of allowing the 80-hour limit to be averaged over four weeks, the limit should apply to each week, as should requirements of providing one day off per week and in-house call no more often than every third night.

The American Medical Student Association also wants protection for residents and others who report violations. The association notes that when Madsen reported Johns Hopkins to ACGME, he “experienced outright hostility and ostracism” and eventually finished his residency training in another program (Ohio State University Medical Center).

AMSA supports passage of a federal law to regulate residents’ hours. Two parallel bills were introduced in the U.S. House and Senate, both entitled “The Patient and Physician Safety Protection Act.” [H.R. 1228, introduced by Rep. John Conyers (D. Mich.), and S. 952, introduced by Sen. Jon Corzine (D. N.J.). The bills were introduced in the 108th Session of Congress, but the bills are expected to be reintroduced in the 109th Congress.]

The proposed federal law would close the “loopholes” cited by the medical student association. The law gives some flexibility by allowing the Secretary of Health and Human Services to promulgate rules to “take into account cases of individual patient emergencies” and to provide that hour limitations would not apply “during a state of emergency” applicable to the hospital.

Penalties for violation of the law include a civil money penalty of up to $100,000 for each resident program in any six-month period. The law also would provide whistleblower protection for residents and other hospital employees who make complaints to hospital management or the government about violations of law. Under the whistleblower protections, hospitals would not be allowed to penalize, discriminate, or otherwise retaliate against an employee who makes a report in good faith. For a comparison of the ACGME requirements and the proposed federal law, see page 18.

The State of New York already has passed a law limiting residents’ work hours. The law took effect in 1989, following an incident in which an 18-year-old woman, Libby Zion, died after receiving what some found to be inadequate care from hospital residents. A grand jury found that there were serious potential dangers to patients from residents who were over-worked, sleep-deprived, and under-supervised. Although Libby Zion’s case did not result in criminal charges, the grand jury report resulted in changes to the state’s Health Code, including limiting residents working schedules to 80 hours per week with no single shifts of more than 24 hours. Other states are considering similar laws.

Recent studies published in the in the New England Journal of Medicine support the need for limiting work-hours of residents (Vol. 351, No. 18, Oct. 28, 2004). A study by Christopher Landrigan, MD, et al, of interns working in medical intensive care units found that “[t]he rate of all serious medical errors was 22.0 percent higher during the traditional schedule [of shifts of 24 or more hours] than during the intervention schedule [with maximum shifts of 16 hours].”

Another study by Stephen Lockley, PhD, et al, said that one quarter of the population, including night-shift workers and residents, “is particularly sensitive to sleep loss” and that “chronic sleep restriction imposed during residency training [places the residents] and their patients at markedly increased risk for fatigue-related errors.”

In the Lockley study, researchers used continuous electrooculography (EOC), measuring slow eye movements during working hours. The researchers said, “The presence of slow-rolling eye movements during wakefulness is indicative of profound fatigue in both occupational settings and laboratory settings....” Attentional failures occurred at more than twice the rate for interns working night shifts on a traditional schedule (with an average of 84.9 hours per week) versus interns working night shifts on an intervention schedule (with an average of 65.4 hours per week).

A third study published in the New England Journal of Medicine (Vol. 352, No. 2, Jan. 13, 2005) by Laura Barger, PhD, et al, reports that residents working an extended shift of 24 hours or more are 3.2 times more likely to be involved in a motor vehicle crash or near-miss than residents who did not work an extended shift. Other studies report that additional problems faced by residents working long hours include increased rates of depression, pregnancy complications, and marital problems.

As hospitals are faced with cutting back on the number of hours that residents traditionally have worked, multiple strategies are being employed, including increased use of nurse practitioners and physician assistants, more use of technology to promote efficiency, and increased workloads for attending physicians.

Jeffrey Drazen, MD, the editor in chief of the New England Journal of Medicine, said in an editorial (Oct. 28, 2004): “[W]e need to learn more about effective teamwork if we are to adapt to schedules that involve frequent handoffs. The key physicians on a team must learn the essential information about every patient, not just enough to get by.” g