Ask, But Don’t Tell
In January 2007, the Accreditation Council for Graduate Medical Education (ACGME), which oversees medical residency programs in the US, began conducting its annual survey of residents and fellows on the compliance of programs to the standards set by the accreditation body. The confidential survey, which will be conducted until June, will take place in roughly half of the country’s residency programs. The ACGME views the survey as an important “diagnostic tool,” but to people seriously concerned about resident work hours, the survey serves as an annual reminder of the ACGME’s inability to enforce its own requirements regarding work hours.
The survey’s greatest concern is whether residency programs are complying with the ACGME’s regulations governing resident work hours. Questions ask if mandates limiting the work week to 80 hours (averaged over four weeks) and continuous work shifts to 30 consecutive hours are respected. They also inquire if residents receive at least ten hours off between work shifts for rest, and are scheduled for overnight call no more often than every third night — both ACGME requirements as well.
Doubting the Data
However, many physicians and others concerned about long resident work hours have attacked the ACGME survey process as an ineffectual method of determining and enforcing compliance with hour regulations. These critics point out that because the only punitive option that the ACGME can wield against noncompliant programs is loss of accreditation, many residents fear that a poor showing on the survey could abolish their program and thus derail their professional plans. Faced with such a great risk, they grudgingly report false data to ACGME to show their programs’ compliance.
Moreover, the survey data only serves as a guide for the on-site visit, which the ACGME uses as its ultimate resource in determining a program’s compliance. Residency programs are usually informed of the date of their on-site visit at least 110 days in advance, providing them ample time to prepare a schedule that, while looking good to the inspectors, is hardly an accurate reflection of the reality that exists when there is less scrutiny.
It Just Doesn’t Add Up
The problematic nature of the survey is clearly displayed in the wide disparity between the findings on work hours compliance reported by the ACGME, and those reported in independent surveys of residents. Since instituting work hour regulations in 2003, the ACGME has reported near unanimous compliance with their standards. During the last academic year, the ACGME proclaimed that less then three percent of residents worked hours exceeding its established limits.
Compare that to the numbers found in a recent study published in the September 6, 2006 issue of the Journal of the American Medical Association by independent researchers from Harvard which indicate that 83.6 percent of the residents surveyed had worked hours that breached some degree of ACGME regulations. The study found that 67.4 percent of the residents sampled reported working shifts longer than 30 consecutive hours, and that 43 percent worked more than 80 hours weekly, even when averaged over four weeks. Additionally, 43.7 percent of residents did not receive one day in seven off from work.
On top of the frequent violation of ACGME regulations, a mounting body of scientific evidence indicates that even the current hour limits defined by the ACGME do not provide adequate protection against chronic fatigue, putting both doctors and patients in danger.
The ACGME survey displays the accreditation body’s powerlessness to enforce its own mandates. More dangerously, by creating distorted data that minimizes the scope of work hours abuse, the ACGME survey stifles honest and realistic efforts toward addressing the ill-effects of long work hours for the good of physicians-in-training and patients alike.
For this reason, the Committee of Interns and Residents/SEIU and the American Medical Student Association lobby for reduced resident work hours at both the state and federal levels, along with real enforcement for reduced work hours, which can only be assured with independent, third-party verification.