Physicians

Petitioners Ask OSHA to Regulate Resident Physician Work Hours

On September 2, Assistant Secretary David Michaels for Occupational Safety and Health received a petition requesting that OSHA regulate resident physician and subspecialty resident physicians.  “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 petition requests that OSHA exercise the authority granted under §3(8) of the Occupational Safety and Health Act to implement the following federal work-hour standard:

(1)   A limit of 80 hours of work in each and every week, without averaging;

(2)   A limit of 16 consecutive hours worked in one shift for all resident physicians and subspecialty resident physicians;

(3)   At least one 24-hour period of time off work per week and one 48-hour period of time off work per month for a total of five days off work per month, without averaging;

(4)   In-hospital on-call frequency no more than once every three nights, no averaging;

(5)   A minimum of at least 10 hours off work after a day shift, and a minimum of 12 hours off after a night shift;

(6)   A maximum of four consecutive night shifts with a minimum of 48 hours off after a sequence of three or four night shifts.

More information about the petition can be found at the Public Citizen-run website, WakeUpDoctor.org.

Present Accreditation Standards

The Accreditation Council for Graduate Medical Education (ACGME), “[a]s the accrediting body for more than 8,800 medical residency programs,… is charged with setting and enforcing standards for supervision and resident duty hours for graduate medical education.”  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.  In 2003, the ACGME set standards that restricted resident work hours to 80 hours per week when averaged over four weeks and no more than 30 consecutive hours of work. (A breakdown of the differences between the OSHA petition and ACGME 2003 standards can be found here.)

In 2007, the Institute of Medicine (IOM) evaluated resident work standards pursuant to a request from Congress. The resulting report, “Resident DutyHours: Enhancing Sleep, Supervision, and Safety” found, among other things, that considerable scientific evidence demonstrates that “30 hours of continuous time awake, as is permitted and common in current resident work schedules, can result in fatigue, and that adjustments to the 2003 rules are needed.” In response, the ACGME proposed revised standards for resident work hoursand supervision. The comment period ended on August 9 and the changes will be implemented after July 2011.

The Substance of the Petition

According to petitioners, the ACGME revised standards are not sufficient.  A study by Landrigan et al. found that even after implementation of the ACGME’s 2003 standards:

  • The average work week was 66.6 hours (95% confidence interval [CI] 66.3-66.9);
  • The mean length of an extended shift was 29.9 hours (95% CI, 29.8-30);
  • 29% of all work weeks were more than 80 hours in duration, 12.1% were 90 or more, and 3.9% were 100 hours or more;
  • 83.6% of all interns reported hours of work in violation of the professional self-regulations that were established and are being monitored by the ACGME. This number far exceeds the rates of violations reported by resident physicians and residency programs to the ACGME, indicating both that widespread under-reporting exists, and that the ACGME’s enforcement has been ineffective.

According to the petition, these numbers of hours are among the highest in the professional world and negatively affect personal health and safety.  Despite the previous rejection of a similar petition in 2002, the petitioners have changed their strategy in appealing to OSHA:  “Whereas previous appeals to limit resident physicians’ work hours have focused on the well-documented risks patients face due to tired physicians, this petition concentrates on the often-overlooked health risks faced by the resident physicians who endure those long hours.”  These risks include:

  • Motor Vehicle Accidents — In addition to anecdotal evidence that resident fatigue after long work hours has resulted in physical injury and death, the petition offered the following research:
    • Journal of the American Medical Association (JAMA) informal survey found that “[o]f seven surgical residents in our hospitals who we interviewed, six fell asleep while driving to or from workduring their internships and three were involved in motor vehicle accidents.”
    • New England Journal of Medicine (NEJM) study found that “risk of a motor vehicle crash was increased significantly following awork shift of 24 hours or greater,” as well as the risk of a near miss.
    • Sleep deprivation researchers at John Hopkins Hospital found that “[f]orty-nine percent of resident physicians [questioned] reported falling asleep at the wheel (not necessarily at a stop light), and 90% of these events occurred after the resident physicians had worked an extended duration (> 24-hour) shift.”
    • An Anesthesiology abstract reported that 17% of survey respondents reported post-call automobile accidents and 72% reported near misses.
  • Mental Health
    • One study described “house officer stress syndrome.” Caused in large part by sleep-deprivation and excessive work load, physicians-in-training may suffer from (1) episodic cognitive impairment, (2) chronic low-grade anger with outbursts, (3) pervasive cynicism, (4) family discord, (5) depression, (6) suicidal ideation and suicide, and (7) substance abuse.
    • Four studies demonstrated that residents are unhappy, face high levels of stress, and suffer “major problems” in their personal relationships with others.
    • Three studies demonstrated that on-call residents reported greater mood disturbance and increased negative mood than those who were rested.
    • One study found that as many as 30% of residents experience depression during their residencies.
    • study published in the Archives of Internal Medicine found that 21% of residents reported depressed scores on the Center for Epidemiological Studies-Depression (CES-D) scale and that depressed responses increased with longer work weeks. Two other studies also found increased rates of depression among residents that correlated with high work hours.
  • Pregnancy
    • NEJM study reported that premature labor and preeclampsia or eclampsia was twice as common among pregnant residents as the wives of male residents and that residents working more than 100hours per week in the third trimester were twice as much at risk for preterm delivery than those that worked fewer than 100 hours.
    • The pre-term labor and preeclampsia risk was validated by a study published in Obstetrics and Gynecology.
    • One study found that infants born during residency significantly more likely to be born with intrauterine growth restriction.
  • Percutaneous Injuries (such as needlestick injuries)
    • JAMA study of self-reported percutaneous injuries in residents found that substantially increased risk during day shifts after overnight call as compared with day shifts not preceded by overnight call.
    • “An Annals of Surgery study from 2005 found that 20 to 38% of all procedures in one urban academic teaching hospital involved exposure to HIV, HBV or HCV.”
    • A NEJM study found that 99% of all residents had suffered a needlestick injury by their final year of study. Fatigue was the second most common reason given for the injury.

Additionally, this petition has more public support than the one submitted in 2002.  Petitioners include:

Response to the Petition

In order to fulfill OSHA’s mission “to send every worker home whole and healthy every day,” the petition argues that OSHA must “act now to address the dangers that extreme work hours pose for resident physicians and subspecialty resident physicians.”

In a statement released the same day, Assistant Secretary Dr. David Michaels recognized the concerns raised by the petition:

We are very concerned about medical residents working extremely long hours, and we know of evidence linking sleep deprivation with an increased risk of needle sticks, puncture wounds, lacerations, medical errors and motor vehicle accidents. We will review and consider the petition on this subject submitted by Public Citizen and others.

The relationship of long hours, worker fatigue and safety is a concern beyond medical residents, since there is extensive evidence linking fatigue with operator error… All employers must recognize and prevent workplace hazards. That is the law. Hospitals and medical training programs are not exempt from ensuring that their employees’ health and safety are protected.

However, ACGME believes that the revised rules under development are adequate.  According to medpagetoday.com, the ACGME said the following in a prepared statement:

As the Occupational Safety and Health Administration reviews a petition from three special interest groups requesting federal regulation of resident duty hours, the Accreditation Council for Graduate Medical Education stands ready to share with OSHA the many studies, evidence, and documentation that substantiate the standards proposed by the ACGME Task Force on Quality Care and Professionalism.

This article originally appeared on Health Reform Watch, the web log of Seton Hall University School of Law, Health Law, & Public Policy Program.

Katherine Matos is a 3rd year student at Seton Hall Law and a regular blogger atHealth Reform Watch.. She is the principle inventor on a patent application in the field of medical imaging, resulting from her research as a student at Stevens Institute of Technology. After graduating with degrees in biomedical engineering and history in 2008, she volunteered with the Irish government in the Health Services Executive. At Seton Hall Law, Katherine has researched federal oversight of nanotechnology with Professor Jordan Paradise and non-profit governance with Professor Melanie DiPietro. She worked as a summer associate at Fitzpatrick, Cella, Harper & Scinto in 2009 and at Robinson & Cole in 2010.

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Virgielaurenszkolenia bhp on-lineszkolenie bhp onlineEasy Safety Recent comment authors
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Virgie
Guest

Howdy! Do you use Twitter? I’d like to follow you if that would be ok. I’m definitely enjoying your blog and look
forward to new posts. Virgie

lauren
Guest

We are intrigued along with interested in what you will be writing about the following.

szkolenia bhp on-line
Guest

nice article, good job:)

szkolenie bhp online
Guest

nice article, good job

Easy Safety
Guest

I think standardizing and limiting hours makes sense in terms of keeping employees in the health care sector healthy and happy, but perhaps some employees would be against this, so I would recommend employees choice.

ExhaustedMD
Guest
ExhaustedMD

So, if this argument to further limit the hours of doctors allegedly has merit, then what are you advocates saying? That the majority of those of us who worked the 80+ hours for several years in our training, and continued to do so depending on the specialty for years since, are incompetent, inefficient, and impaired? For those who answer yes, I advise readers to pay attention to said writers and review their comments elsewhere to see the pattern. Because the agenda here is either: detract from the real needs of training and providing care as a licensed MD; dumb down… Read more »

Hells.Mascot
Guest
Hells.Mascot

Exhausted MD: You seem to have a complete disregard for the concept that someone who is overworked and possibly debilitated in performance of their job is a very unsafe thing in a profession where other people’s lives are at stake on a very regular basis, regardless of whether the rigors of the employee are thought to be commonplace or not.

ExhaustedMD
Guest
ExhaustedMD

Health care is not a 9 to 5 job. And I find the commentary by non-clinicians to be both useless and inappropriate in these failed efforts at analogies and assumptions. Sorry, basically from what I have read in the past few years, the current physician in training is looking for an easy ride in a profession that is demanding and expecting of strong committment. If being a doctor is so easy, as some of you imply in your writings, then why aren’t 300 or more people admitted to every med school each year? Because it is embarassing to flunk out… Read more »

MedInformaticsMD
Guest

Having done these types of shifts myself in internship in the early 1980’s, and having suffered for it under the situation at that time of having had symptomatic WPW sydrome (no longer; radioablation 1995) and being on energy-sapping drugs, for which The Chief made no accommodation, the shift towards concern for the health of the provider of care is notable and commendable. An issue might be, would residents be considered employees, or students by the courts? Regarding the IOM’s observation that “considerable scientific evidence demonstrates that “30 hours of continuous time awake, as is permitted and common in current resident… Read more »

bill buchta
Guest
bill buchta

ExhaustedMD, even your chosen “handle” speaks against the status quo; if they aren’t beaten up so much in residency, maybe trainees would be more thoughtful and engaging as practitioners, besides being alive.
And to Gary Lampman, are you really putting healcare workers in the same risk category as sex workers? Can’t you give us credit for exercising reasonable controls and having the professionalism to protect the public from our known communicable diseases? Don’t shackle the whole group based on a very, very few bad apples.

Dr. Rick Lippin
Guest

The health of healthcare workers is one of our nation’s most glaring paradoxes
OSHA could help at all levels
Instead we are forcing healthcare workers to take mandatory flu shots
Dr. Rick Lippin
Southampton,Pa

plangix
Guest
plangix

I think it’s a nice idea. Regulating working hours is a fair scheduling. –april

Gary Lampman
Guest
Gary Lampman

Doctors need restrictions on hours as much as truck drivers are regulated with the amount of time they can travel on our Highways. Overworked Doctors and nurses are no less lethal than a tractor trailer driver that falls asleep at the Wheel! These judgement calls are difficult enough at optimal performance and readiness. However,the incrimental increase of work hours translates toward greater patient risks due to impaired judgement by Health Care Professionals. It makes a great deal of sense to ensure the publics Wellfare is not endangered from over worked and understaffed work environments. Matter of Fact, I would also… Read more »

propensity
Guest
propensity

OSHA would do better to investigate the mind numbing and eye sight blurring fonts of the HIT devices in front of which the doctors and hospital staff sit and
over which they pore, for hours on end.
This is not safe, for neither users nor patients.

J.S.
Guest
J.S.

“Public Citizen” — Ralph Nader’s front group. Let them screw up HC like they did the Detroit 3.
More yapping, nothing done on the front line. Gimme a break — hasn’t Harvard Law OWEbama done enough to $@%# things up?