OP-ED

Drawing a Hard Line on Resident Work Hours

Last year, Public Citizen and other groups filed a petition – the second in 10 years – calling on the Occupational Safety and Health Administration (OSHA) to take over responsibility for enforcing medical resident work hours from the Accreditation Council for Graduate Medical Education (ACGME). This past September, the Obama administration denied our groups’ petition on the grounds that the ACGME is the appropriate entity to handle the issue, an identical argument to one put forward by the Bush administration nine years earlier to justify the denial of our first petition.

Both petitions were filed as a result of the long-standing failure of the ACGME to adequately protect residents from the proven deleterious effects of long work hours. Six years after the ACGME implemented the first limits on resident work hours in 2003, the Institute of Medicine (IOM) concluded an exhaustive 12-month review examining the existing system of medical training and the evidence regarding fatigue, resident physicians, and patient safety. The IOM concluded that the 2003 ACGME rules were not adequately protective and that major changes were needed, including a limit of 16 hours in a row for all resident work shifts.

In response, the ACGME updated its guidelines in 2010, but unfortunately, the new rules failed to incorporate the majority of the IOM’s recommendations. The rules limited medical interns ― first-year residents ― to 16-hour shifts but inexplicably allowed all other residents to continue to work up to 28 hours straight. There is no biological rationale to support the notion that residents suddenly become able to withstand the adverse effects of extended shifts upon completing their first year of residency. In addition, the new rules, in permitting averaging over several weeks to achieve the 80-hour weekly limit, continued the practice of allowing residents to work 100 or more hours in certain weeks.

Years of evidence has made clear that hours this long are a serious hazard to resident health. Residents working longer hours suffer a higher rate of post-shift motor vehicle accidents, needle stick injuries, obstetric complications, and mood disorders than those working shorter shifts. Patient safety is also compromised when residents must make life and death clinical decisions while trying to stay awake after an overnight shift, as has been shown in numerous studies.

Arguments against stricter work hour limits have traditionally centered on concerns that the long hours are necessary to ensure that residents receive an adequate education. However, a systematic review of studies exploring this question found that, in 13 out of 14 studies reviewed, educational outcomes did not change, or even improved, with reduction or elimination of shifts greater than 16 hours.

Others argue that patient safety would be compromised from excessive handoffs of duties between residents during shift-changes.  This too has been disproven. As the IOM pointed out, duty handoffs can easily be standardized to avoid missing vital patient information, with the report highlighting numerous examples of programs that have implemented such protocols successfully.

The reality is that there are no credible arguments against setting stronger work hour limits that were not already raised by opponents to these limits back in 2003 when the first rules were put into place. At that time, dire warnings that residents would not be prepared for “real-world” medicine and that patient care would suffer did not pan out. Eight years later, few physicians would prefer to return to the pre-2003 days.

The failure to align policy with the science on the hazards of sleep deprivation is not due to a lack of expert consensus, but rather a lack of willingness on the part of the major actors involved. The ACGME has a vested interest in monopolizing oversight of residency programs in what is a form of self-regulation by academic hospitals that are not willing to submit to the same public oversight that is standard across almost all other industries. The federal government under OSHA, for its part, is shirking its responsibility out of a desire to avoid stepping on the ACGME’s toes in enforcing an issue it has for too long conceded to the private organization.

Yet, both entities are acting against the will of the overwhelming majority of the American public, which believes that resident hours should be more restricted. In a 2010 phone survey of 1,200 people, only 2% believed that residents should be allowed to work shifts longer than 24 hours, and 86% believed that weekly limits should be set at less than the current 80 hours.

In addition to safer work hour limits, our petitions called on OSHA to fulfill what is clearly its legal obligation to regulate existing standards. As an initial step, public oversight of resident work hours would complement, rather than replace ACGME enforcement. Unlike the ACGME, OSHA has the authority to issue monetary penalties to hospitals and programs that are particularly egregious violators of resident work hour rules. Moreover, OSHA is able to conduct random, unannounced inspections of hospitals, rather than merely rely on work hour logs submitted by residents. And in contrast to the ACGME, OSHA can hold accountable hospitals that retaliate against residents for coming forward about work hour violations, making it more likely that residents would feel secure in reporting the violations. These measures would spur compliance with safe work hour practices, while addressing the widespread under-reporting of violations that currently exists.

The academic hospital industry is one of the few remaining sectors of the U.S. workforce where workers go unprotected by OSHA. No other industry enjoys such a privilege. The fact that not only worker health, but the public’s health, is at stake, and that these hospitals receive billions in annual Medicare funding should serve as even more reason for the government to step in and meet its legal obligation to protect residents and patients. While the ACGME has, and must continue to have, an important role in supervising the nature of residents’ education, as a private entity, it should not be allowed to determine the conditions under which residents work. This is clearly OSHA’s domain. Public oversight of resident work hours is necessary and long overdue.

Sammy Almashat is a research associate at Public Citizen’s Health Research Group. Sidney Wolfe is director of the Health Research Group, which promotes research-based, system-wide changes in health care policy and provides oversight concerning drugs, medical devices, doctors and hospitals and occupational health.

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DaveSJ MotewsteveSJ Motew, MDChuck Watts Recent comment authors
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Dave
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Dave

Cut out the piles and piles of paperwork that doubles every ten years and we can do more in much less time. Why don’t you fix that, OSHA?

steve
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steve

1) Taking call is a fact of life. If docs have to take call at small hospitals, 24 hour shifts are not avoidable.

2) I know what the literature says, and maybe I have just been unlucky, but the new staff I have hired our of residency/fellowship are clearly not ready to work independently. These are people coming out of the Cleveland Clinic or equivalent level of program.

Steve

SJ Motew
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SJ Motew

I have seen the same. Most new hires have not had to experience a full night call and busy office the next day and are quite surprised and unprepared. Hence my post suggesting the whole system would need to change. The fact of current medical economics though require these high levels/hours of work to sustain the expected income. One cannot simply maintain the same level of revenue with less hours under our current volume-based reimbursement model.

steve
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steve

Even cutting revenue, how would you cover 24 hour call at a hospital that can support only 2 docs? Heck, I need to provide 24 hour coverage to a small hospital that has enough daytime work to pay for one physician. How do I do that?

Steve

SJ Motew, MD
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SJ Motew, MD

While increasing resident work hour regulation may be appropriate, the reality is that ‘real-world’ work hours post-training frequently demand exceeding these limitations. While surveys may suggest no one wants to return to previously unrestricted hours, the current workforce is ill-prepared (at times).

My point is not necessarily to support longer hours, but without reform of the entire care paradigm,i.e. maintaining limits after residency, then any regulation will have little lasting benefit.

Chuck Watts
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Here’s a White House petition that might help your work. http://wh.gov/jvk