Medical resident work hours

Medical resident work hours is a term that refers to the often lengthy shifts worked by medical interns and residents during their medical residency. The issue has become a political football in the United States, where federal regulations do not limit the number of hours that can be assigned during a graduate medical student's medical residency. In 2007, regulations capped the work-week at 80 hours as noted in the 'ACGME Duty Hours Language'.

Long hours

Medical residencies traditionally require lengthy hours of their trainees. The American public, and the medical education establishment, is increasingly recognizing that such long hours are counter-productive, since sleep deprivation increases rates of medical errors. This was noted in a landmark study on the effects of sleep deprivation and error rate in an intensive care unit.^[1] The Accreditation Council for Graduate Medical Education (ACGME) has limited the number of work-hours to 80 hours weekly, overnight call frequency to no more than one overnight every third day, 30 hour maximum straight shift, and 10 hours off between shifts. While these limits are voluntary, adherence has been mandated for the purposes of accreditation.

Most recently, the Institute of Medicine (IOM) built upon the recommendations of the ACGME in the December 2008 report Resident Duty Hours: Enhancing Sleep, Supervision and Safety. While keeping the ACGME's recommendations of an 80-hour work week averaged over 4 weeks, the IOM report recommends that duty hours should not exceed 16 hours per shift, unless an uninterrupted five-hour break for sleep is provided within shifts that last up to 30 hours. The report also suggests residents be given variable off-duty periods between shifts, based on the timing and duration of the shift, to allow residents to catch up on sleep each day and make up for chronic sleep deprivation on days off.

Critics of long residency hours trace the problem to the fact that resident physicians have no alternatives to positions that are offered, meaning residents must accept all conditions of employment, including very long work hours, and that they must also, in many cases, contend with poor supervision.[1] This process, they contend, reduces the competitive pressures on hospitals, resulting in low salaries and long, unsafe work hours.

Towards an 80 hour work week

Regulatory and legislative attempts at limiting medical resident work hours have materialized, but have yet to attain passage. Class action litigation on behalf of the 200,000 medical residents in the US has been another route taken to resolve the matter.^{[citation needed]}

Dr. Richard Corlin, president of the American Medical Association, has called for re-evaluation of the training process, declaring "We need to take a look again at the issue of why is the resident there."[2]

The U.S. Occupational Safety and Health Administration (OSHA) rejected a petition seeking to restrict medical resident work hours, opting to rely on standards adopted by ACGME, a private trade association that represents and accredits residency programs.[3] On July 1, 2003, the ACGME instituted standards for all accredited residency programs, limiting the work week to 80 hours. These standards have been voluntarily adopted by residency programs.

On November 1, 2002, the 80-hour work limit went into effect in residencies accredited by the American Osteopathic Association (AOA). The decision also mandates that:^[2]

1. The trainee shall not be assigned to work physically on duty in excess of 80 hours per week averaged over a 4-week period, inclusive of in-house night call.
2. The trainee shall not work in excess of 24 consecutive hours inclusive of morning and noon educational programs. Allowances for inpatient and outpatient continuity, transfer of care, educational debriefing and formal didactic activities may occur, but may not exceed 6 hours. Residents may not assume responsibility for a new patient after working 24 hours.
3. The trainee shall have on alternate weeks 48-hour periods off, or at least one 24-hour period off each week, averaged over a 4-week period.
4. Upon conclusion of a 24-hour duty shift, trainees shall have a minimum of 10 hours off before being required to be on duty again. Upon completing a lesser hour duty period, adequate time for rest and personal activity must be provided.
5. All off-duty time must be totally free from assignment to clinical or educational activity.
6. Rotations in which trainee is assigned to Emergency Department duty shall ensure that trainees work no longer than 12 hour shifts.
7. The trainee and training institution must always remember the patient care responsibility is not precluded by the work hour policy. In cases where a trainee is engaged in patient responsibility which cannot be interrupted, additional coverage should be provided as soon as possible to relieve the resident involved.
8. The trainee may not be assigned to call more often than every third night averaged over any consecutive four-week period.

Effects on health

A study of over 8 million hospital admissions of Medicare beneficiaries published in 2007 comparing mortality rate before and after implementation of the ACGME standards showed no difference in mortality.^[3] However, it is largely felt that actual duty hours (opposed to reported duty hours) have not changed substantially, and this explains this result. Prior to a change in work hours, residents were working, on average 82 hours per week.<Dr. Charles Czeisler, APSS 2009 6.9.09>. The study relies on self reported hours. A significant bias to under report hours worked exists for two important reasons. One is that statutes do not provide whistleblower protections to residents who report work hour violations. Second, the penalty for work hour violation is loss of accreditation, which would adversely affect the medical resident since he would not be able to become board certified in his/her field of medicine. Furthermore, an accompanying study done in the Veterans Administration setting (with 318,636 patients) by the same researchers showed that work hours restrictions reduced mortality substantially for a similar set of diagnoses ^[4]. Another study found that the 2003 ACGME reforms restrictions were associated with a small reduction in the relative risk for death in 1,268,738 non-surgical patients drawn from a national survey of hospitals ^[5].

Research from Europe and the United States on nonstandard work hours and sleep deprivation found that late-hour workers are subject to higher risks of gastrointestinal disorders, cardiovascular disease, breast cancer, miscarriage, preterm birth, and low birth weight of their newborns.^[6] Chronic sleep deprivation and the resulting fatigue and stress can affect job productivity and the incidence of workplace accidents.^[7] There are also social effects. Married fathers in the United States who work fixed night shifts are 6 times more likely than their counterparts who work days to face divorce; for married mothers, fixed nights increase the odds by a factor of 3.^[8]

See also

• Libby Zion law
• Stress (biological)
• Work-life balance
• Working Time Directive

References

1. ^ Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA (2004). "Effect of reducing interns' work hours on serious medical errors in intensive care units". N Engl J Med 351 (18): 1838–48. doi:10.1056/NEJMoa041406. PMID 15509817. 
2. ^ "ACCREDITATION DOCUMENT FOR OSTEOPATHIC POSTDOCTORAL TRAINING INSTITUTIONS AND THE BASIC DOCUMENT FOR POSTDOCTORAL TRAINING PROGRAMS." Year=10, 2006. Pages=45 of 154. http://www.osteopathic.org/pdf/sir_postdoctrainproced.pdf
3. ^ JAMA - Abstract: Mortality Among Hospitalized Medicare Beneficiaries in the First 2 Years Following ACGME Resident Duty Hour Reform, September 5, 2007, Volpp et al. 298 (9): 975
4. ^ http://jama.ama-assn.org/content/298/9/984.short
5. ^ http://www.annals.org/content/147/2/73
6. ^ See Biological Rhythms: Implications for the Worker, publication OTA-BA-463 (U.S. Congress, Office of Technology Assessment, 1991); Henrik Bøggild and Anders Knutsson, “Shift Work, Risk Factors, and Cardiovascular Disease,” Scandinavian Journal of Work and Environmental Health, vol. 25, no. 2, 1999, pp. 85–99; and Alexander Wedderburn (ed.), “Shiftwork and Health,” special issue of the Bulletin of European Studies on Time (BEST), vol. 1 (Luxembourg, Office for Official Publications of the European Communities, 2000), on the Internet at www.eurofound.ie, (visited Feb. 25, 2008).
7. ^ Kauppinen, Timo (2001). The 24-Hour Society and Industrial Relations Strategies. Oslo, Norway: European Industrial Relations Association. 
8. ^ Presser, Harriet B. (2003). Working in a 24/7 Economy: Challenges for American Families. New York: Russell Sage Foundation. 

External links

• ACGME.org - 'The Accreditation Council for Graduate Medical Education (ACGME) is responsible for the Accreditation of post-MD medical training programs within the United States'
• Resident Duty Hours: Enhancing Sleep, Supervision and Safety. Institute of Medicine