Frequently Asked Questions
- How many hours do resident physicians currently work?
- What is the ACGME?
- What are the problems with ACGME’s enforcement of hours limits?
- What is the history of work hour reform?
- What is the IOM?
- Why are these recommendations important?
- What about the cost of implementation of the IOM recommendations?
- When will the IOM recommendations be implemented?
- Why are CIR and AMSA supporting the IOM recommendations?
Challenging Resistance to Reform
Often, challenges are made to implementing 16-hour shifts, sometimes from professional organizations, program directors, and occasionally from resident physicians themselves. Here are some commonly heard challenges, followed by information disputing these challenges.
- Doctors are professionals and need to always be there for their patients
- They’ve reduced work hours in Europe and it’s a disaster! It will never work here.
- The shorter our hours are, the more handoffs there will be and that means more errors.
- In this economic environment, my hospital just doesn’t have money available.
- Who will do the work? Most residency programs can’t just hire more residents.
- My attendings say that when we finish training, we’ll be unprepared to work long hours.
- The IOM didn’t listen to residents’ ideas.
- I’m afraid that if resident hours are reduced, my residency will be lengthened.
- I know that the public says that they would like well-rested doctors, but I don’t think that the public understands what it takes to train a doctor. Why should they have a say?
- I prefer to work 24-hour shifts. Sometimes I can get sleep, and then I’ll get a post-call day off. Why should they have a say?
Residents work grueling hours. While hours have improved somewhat for residents after the Bell Regulations took effect in New York State in 1989 and 2003 (see “history of work hour reform” below), residents work extremely lengthy shifts.
Residents frequently work shifts lasting up to 30 hours. While regulations state that residents cannot work greater than 80 hours per week, this may be averaged over one month, meaning that a resident may work 60 hours one week, followed by 120 hours the next week.
The Accreditation Council for Graduate Medical Education (ACGME) is the body responsible for the accreditation for postgraduate medical training programs, as well as evaluation and accreditation of medical residency and internship programs.
Unfortunately, the structure of ACGME makes it the wrong institution for setting and enforcing work hour limits. The ACGME is a private, non-profit organization, and its board members are appointed by the independent healthcare industry organizations that comprise its membership, save one federal representative without voting rights, leaving no formal channels for direct public input and accountability. Moreover, there are disturbing conflicts of interest among the healthcare industry member organizations that make up the ACGME. As articulated by The New York Times on its June 14, 2002 editorial page, “Despite the tough talk, the council faces an inherent conflict of interest. Its board is dominated by the trade associations for hospitals, doctors, and medical school, all of which benefit from the cheap labor provided by medical residents.”[i]
Secondly, the ACGME’s enforcement method has proven ineffective. The only sanction that the ACGME wields over residency programs that violate its work hour limits is loss of accreditation. As a result, many residents are understandably reluctant to report work hour violations to the ACGME, not wanting to risk the derailment of their professional careers by the de-accreditation of their residency program.
Additionally, ACGME’s on-site inspections are typically announced to hospital administrators at least 110 days before their scheduled date, and even then only occur once every two years. New York State, by contrast, contracts an independent, peer-review agency to enforce the State’s own resident work hours regulations through annual, unannounced visits to program sites lasting several days and comparing actual hospital records against “official” published schedules.
The impotency of the ACGME’s enforcement mechanisms can be seen in the wide discrepancy between the ACGME’s own data on compliance, and data collected by independent Harvard researchers and published in the Journal of the American Medical Association in 2006.[ii]
Public concern about the health and safety effects of excessive resident work hours steadily grew throughout the 1980s and 1990s, as new scientific evidence on fatigue, media coverage of medical errors, and common sense drew people’s worried attention to the medical system. In 1987, New York State formed a commission to examine resident training in the state, following the well publicized death of Libby Zion, the daughter of a prominent New York journalist, in a Manhattan hospital under the care of intensely overworked resident physicians. Two years later, the commission’s recommendations for stricter resident work hour limits were instituted as New York State Law, becoming known as the “Bell Regulations” after Dr. Bertrand Bell, the commission’s chair.
As state-level efforts to reduce resident work hours were launched elsewhere following the Bell Regulations, physicians and the concerned public began to increasingly call for federal legislation to address the issue. In 2001, a coalition of doctors and healthcare organizations filed a petition with the Occupational Safety and Health Administration asking for federal oversight of resident work hours as a matter of workplace safety. The same year, Rep. John Conyers (D-MI) introduced congressional legislation limiting work hours, and the bill quickly garnered 71 cosponsors from across party lines.
Facing this wave of public pressure, the ACGME agreed to tighten its resident work hour regulations, in large part to avert the imposition of stronger reform measures. The new ACGME hours regulations took effect July 1, 2003. However, as these current regulations have repeatedly been shown to be inadequate, the need for further action remains clear.
The Institute of Medicine (IOM) is a part of the Unites States National Academy of Sciences, and serves to advise policy-makers, professionals, leaders in every sector of society, and the public of issues of national health. It is an independent, nonprofit organization that works outside of government in order to provide unbiased and authoritative advice. It consists of volunteers in various fields of science who operate under a rigorous, formal peer-review system.[iii]
In 2007, the US House of Representatives Committee on Energy and Commerce requested that the Agency for Healthcare, Research and Quality (AHRQ) investigate resident work hours, as their interest had been “recently heightened” by a study that “found medical errors resulting in adverse events including death, due to sleep-deprived, and over-extended medical residents and interns, substantiating previously held concerns about physician work schedules.” [iv] [v]In 2008, the IOM released a report entitled, “Resident Duty Hours: Enhancing Sleep, Supervision and Safety.”[vi] This report recommended revised duty hours and duty requirements for medical residents in order to improve both education and patient safety. The IOM report grew out of a growing concern for patient safety among congressional leaders on the House Energy and Commerce Committee.
The comprehensive report concluded, “The committee believes there is enough evidence from studies of residents and additional scientific literature on human performance and the need for sleep to recommend changes to resident training and duty hours aimed at promoting safer working conditions for residents and patients by reducing resident fatigue.” [vii]
Most of the buzz from the IOM recommendations has focused on the new work hours limits that it calls for, most notably: A maximum shift length of no more than 16 hours, and if the current 30 hour shift is still in effect, the IOM says a resident must not admit patients after 16 hours and must have a 5-hour protected sleep period between 10 pm and 8 am, with the remaining hours spent only in transition and educational activities. The current 80 hour work week limit, averaged over four weeks, is maintained in the IOM recommendations. Moonlighting (both internal and external) would be counted in the 80 hour limit.[viii]
The IOM also recommends doing away with the current system that allows an every third night on-call schedule to be averaged over the course of a month. This loophole has allowed residents to work 30 hour shifts every other night for a week or more at a time. “Q2 call” is still common in many surgical training programs, as residents must cover for a colleague away on vacation, or work an ‘every other’ in order to get one full weekend off each month (aka the “golden weekend.”) In fact, the IOM recommends that residents should have more time off – a mandatory five days off per month, including 24 hours off per week (no averaging) and one 48 hour period off per month. Time off between day shifts remains at the current ACGME limit of 10 hours, but the IOM recommends an increase to 12 hours after a night shift and 14 hours after a period of 30 hours. After hearing testimony about the deleterious effect of working many nights in a row, the IOM recommended limiting night shifts to four nights in a row maximum, with 48 hours off after 3 or 4 nights of consecutive work.[ix]
In reaching the conclusion that residents need more time for sleep, the IOM report cites decades of overwhelming scientific evidence, including research that “as a fundamental biological function, sleep both stabilizes waking performance and enhances the ability to learn and remember.”[x]
Certainly the IOM recommendations are a significant departure from what is now ACGME policy – and there is universal agreement that implementation will be a challenge. Importantly, however, the IOM report takes a much broader look at residency training, recognizing that work hours should not and cannot be viewed – or reduced — in a vacuum. Some of the big questions that the IOM report tackles are resident workload, ancillary staffing, resident supervision, oversight, resident safety, and effective handovers.
“To avoid having residents bear the burden of implementing the duty hour recommendations by increasing their workload again, and increasing the risk to patient safety,” writes the IOM,” additional funds for graduate medical education (GME) are needed from all existing as well as new sources.”[xi] The IOM Report calls upon GME financial stakeholders (CMS, VA, Dept of Defense, states and local governments, private insurers and teaching hospitals, etc.) “to financially support the changes necessitated by the committee’s recommendations to promote patient safety and resident safety and education, with special attention to safety net hospitals.” IOM consultants attempted to quantify this expense and estimated that the cost of hiring staff substitutes, other health care providers or additional residents “could be approximately $1.7 billion — only about .4% of the Medicare budget.[xii]
We know that sleep deprivation associated with longer work hours is associated with medical errors. Studies have shown the following: That residents working a traditional Q3 schedule (24-30 hour shifts every third night) suffered twice as many attentional failures, and made 36% more serious errors than residents on an interventional schedule limiting shifts to 16 hours,[xiii] [xiv] , and that residents working a heavy call schedule had a higher degree of impairment than controls with a 0.05% blood alcohol level when performing tests of sustained attention, vigilance, and simulated driving tasks, often while being unaware of their impairment.[xv]
Finally, a meta-analysis of 60 resident work hours studies found that sleep deprivation of 24-30 hours leads to a significant decrease in clinical performance and vigilance. [xvi] The cost of enacting the IOM recommendations pales in comparison to the financial and ethical costs of preventing medical errors.
They won’t be – unless the ACGME decides to act — or Congress acts for them. The ACGME has begun an 18-month period of review, to conclude at the earliest in 2010. Then, if the timetable for hours limits introduced in 2003 is any guide, it will be another year until any changes went into effect. The ACGME is facing a lot of opposition from hospitals and residency programs who want to continue to schedule residents for 30 hour shifts, despite the evidence linking acute and chronic sleep deprivation with increased medical errors. However, some ACGME leaders are afraid that if they don’t act on the evidence and reduce resident hours, then they will face federal regulation – something they very much want to avoid.
We insist on the importance of acting on the evidence when it comes to effective treatment for heart disease and cancer or choosing one surgical procedure over another. How then can we NOT act on the compeling evidence that serious fatigue contributes to medical errors, not to mention resident car crashes, needlestick injuries, depression and burnout? Every other industry in the U.S. that is responsible for public safety has been regulated by government to ensure that employees are not scheduled to work beyond what is safe.
The long hours that residents are required to work today is rooted in an out-dated training system that needs to be modernized. CIR believes that patient safety and resident education and quality of life will be improved if the IOM recommendations are implemented. CIR also believes it is very important that the necessary funding be provided and that residents be included in the work re-design. Medicine has changed and will continue to change in our lifetimes and reducing work hours is going to be part of that change. Rather than spending valuable time and resources fighting this reform, CIR thinks that the ACGME should be working to ensure that it happen in as timely and effective a way possible.
Challenging Resistance to Reform
- Doctors are professionals and working long hours is part of the job. I need to be there for my patients.
Part of being a professional today is understanding the role that lack of sleep plays in patient and resident safety. Reviewing the substantial body of evidence on human performance and sleep deprivation, the Institute of Medicine came to the conclusion that “Professionalism should not just mean staying long hours” and that “ensuring adequate sleep for residents is part of responsible behavior to promote safe conditions for both residents and patients.”
There’s a lot of research out there now that points to the importance of the health care team in providing quality care. The romantic notion of the physician sitting for hours at the patient’s bedside, observing the progression of disease is not compatible with today’s hospital, where a premium is put on getting patients in and out. Teamwork and communication are now recognized as essential components of continuous, quality care and mastering those skills is what it means to be an effective professional.
Some opponents of the IOM recommendations have equated them to the European Working Time Directive’s rules. In the UK (the only European country that has implemented the Directive), resident work hours were reduced from 72 hours/week to 58 in 2004 and are mandated to drop to 48 hours later in 2009. (Actual implementation of these hours varies widely). The IOM is recommending that the current ACGME weekly limit remain at 80 hours (averaged over four weeks)
It’s worth noting that the IOM report concluded that the European model of training physicians was very different from the U.S. model and therefore it was not useful to compare experiences. While the differences in training are significant, there is still a lot to learn from the UK experience, as they have many innovative scheduling ideas (e.g. Hospital at Night) and are more advanced in their implementation of the team approach to health care delivery. To find out more, go to www.healthcareworkforce.nhs.uk.
- The shorter our hours are, the more handoffs there will be and that increases the likelihood for errors more than working long hours.
Everyone recognizes that residents have to go home sometime, so hand-overs will always be necessary. There’s a lot of research out there detailing what constitutes a quality transfer of patient information and doctors need to work on perfecting that. However, receiving sign-out from a colleague who has been up for more than 24 hours (and can only think about getting to bed) is far from ideal.
- In this economic environment, it’s impossible to think there will be money available. My hospital just doesn’t have it.
Times are tough and you’re right – hospitals won’t voluntarily decide to spend their limited resources on re-engineering resident work. Why should they, when they’ve always been able to count on residents to work extremely long hours and do the work of many other hospital staff? The Institute of Medicine report calls for additional funding for graduate medical education in order to reduce resident hours and improve supervision. The report reviewed the evidence and maintains that even a small reduction in preventable adverse events will offset the additional cost.
- Who will do the work if resident hours are reduced? Most residency programs can’t just hire more residents.
There’s considerable discussion now about whether or not the federal government should raise the “caps” on the number of residents that it pays to train. Some of that pressure comes from the overall shortage of general surgeons and primary care physician — and the shortage of some specialists in under-served areas of the country. At a time when the nation wants to expand access to health care, increasing the number of physicians trained in the U.S. is a real possibility.
Additionally, much work that residents do is considered “scutwork”, work such as drawing blood or requesting medical records. This work could be done by ancillary staff. Additional funding could provide for this staff and maximize learning during the hours that residents work.
- My attendings are hostile to any reduction in resident work hours. They say that when we finish training, we’ll be unprepared to work the long hours that they do.
Unfortunately, the evidence on the link between sleep deprivation and increased medical errors does not back up the practice of working such long hours. The Institute of Medicine’s panel of experts spent a year reviewing all of the scientific literature. It concluded that there was sufficient data to conclude that work hours for residents needed to be reduced – to increase patient safety and the safety of residents driving home post-call.
The IOM report did not address the fact that many attendings do work long hours – and physiologically are just as prone to the negative affects of sleep deprivation as residents and all other human beings. It is only a matter of time before the quality movement in health care takes up the role of sleep in preventing adverse events. The public is already there. In a 2004 Kaiser Family Foundation nationwide survey of public opinion on the causes of medical errors, 74% of respondents listed “overwork, stress or fatigue of health professionals as a “very important cause of medical errors,” and 66% felt “reducing the work hours of doctors in training to avoid fatigue” would be “very effective in reducing preventable errors.”
Congress is also increasingly concerned about medical errors because of the huge cost to our health care system. Congress requested that the Institute of Medicine review all of the available evidence on sleep deprivation and medical errors. The IOM panel was made up of experts in the field of sleep science, human engineering, hospital administrtion and medical education, as well as a resident and a consumer. It reviewed the literature and heard
hours of testimony from residency program directors who argued that no change in resident work hours was necessary. In the end, the IOM panel produced a 428-page report concluding that the evidence made a compelling case for the necessity to reduce the hours that residents work – as well as other changes in the way physicians are trained.
- I’m afraid that if resident hours are reduced, my residency will be lengthened. I’d rather suffer through the time I have now than see it lengthened.
Opponents of reducing hours wave that red flag – but there’s no inherent reason why that should happen, especially because the federal government is not going to want to pay for longer training! It’s much more likely that resident hours will be reduced by re-engineering the way that education and patient care are organized. Every resident can point to inefficiency and wasted time in the way their residency is run now. That re-engineering will be different for different specialties and different hospitals – and residents need to have a say in how happens. Some of that change will require additional resources to hire physician extenders, hospitalists, etc.
- I know that the public says that they would like well-rested doctors, but I don’t think that the public understands what it takes to train a doctor. Why should they have a say?
The public deserves a say in this issue, because as it turns out, they’re right! Not only is it common sense that a well-rested doctor will make better decisions, but science supports this as well. The IOM report cites decades of overwhelming scientific evidence, including research that “as a fundamental biological function, sleep both stabilizes waking performance and enhances the ability to learn and remember.”
Additionally, a 2004 New England Journal of Medicine article showed that 24-hour shifts caused medical interns to be twice as likely to suffer attentional failures at night and 35.9 percent more likely to commit a serious medical error. With an overwhelming number of medical errors being made in our health system, the public has the right to demand that their doctor take every precaution to avoid medical errors, something a doctor is unable to do when they are sleep-deprived.
- I prefer to work 24-hour shifts. I feel like I can handle the work. Sometimes I can get sleep, and then I’ll get a post-call day off.
Overwhelming evidence shows that 24-hour shifts leave residents less able to do their jobs. An article published in the journal Sleep showed that residents performing 24-hour shifts every fourth to seventh night (Q4-7) had impaired reaction times and decreased vigilance, both pre- and post-call, suggesting that recovery periods from overnight-calls exceeded several days. More importantly, residents were found to be unaware of their impairment.
What residents may or may not prefer is really not the important issue. Much in the way that it might be easier to not wash our hands between patients, when evidence shows that hand washing decreases infections, physicians are obliged to follow what science says about patient safety and practice evidence-based medicine.
[iv] Dingell JD, Barton J, Stupak B, Whitfield E. Letter written to William Munier, Agency for Healthcare, Research and Quality. Washington DC:U.S. House of Representatives, Committee on Energy and Commerce, March 29, 2007.
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