Medical resident work hours
||The examples and perspective in this article may not represent a worldwide view of the subject. (August 2015)|
Medical resident work hours 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. Starting in 2003, with revisions in 2011, regulations from the Accreditation Council for Graduate Medical Education capped the work-week at 80 hours. Shifts are capped (with limited exceptions) at a maximum of 16 consecutive hours for a first year resident and 24 in the second and third years. 
Medical residencies traditionally require lengthy hours of trainees. The public and the medical education establishment recognize that such long hours are counter-productive, since sleep deprivation increases rates of medical errors and may affect learning, however the phenomenon persists in order to create a higher entry barrier and reduce costs for medical facilities.
This risk was noted in a landmark study on the effects of sleep deprivation and error rate in an intensive care unit. 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 in three, 30-hour maximum straight shifts, and at least 10 hours off between shifts. While these limits are voluntary, adherence has been mandated for accreditation.
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 for interns (PGY 1). The IOM also recommended strategic napping between the hours of 10pm and 8am for shifts lasting up to 30 hours. The ACGME officially recommended strategic napping between the hours of 10pm and 8am on 30 hour shifts for residents who are post graduate year 2 and above but did not make this a requirement for program compliance. 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. This process, they contend, reduces the competitive pressures on hospitals, resulting in low salaries and long, unsafe work hours.
Toward 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.
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."
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. On July 1, 2003, the ACGME instituted duty hours requirements for all accredited residency programs, since revised in 2011.
The ACGME duty hour standards that went into effect in July 2003 require:
- An 80-hour weekly limit, averaged over 4 weeks, inclusive of all in-house call activities;
- A 10-hour rest period between duty periods and after in-house call;
- A 24-hour limit on continuous duty, with up to 6 additional hours for continuity of care and education;
- No new patients to be accepted after 24 hours of continuous duty;
- One day in 7 free from patient care and educational obligations, averaged over 4 weeks, inclusive of call; and
- In-house call no more than once every 3 nights, averaged over 4 weeks.
- 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.
- 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.
- 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.
- 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.
- All off-duty time must be totally free from assignment to clinical or educational activity.
- Rotations in which trainee is assigned to Emergency Department duty shall ensure that trainees work no longer than 12 hour shifts.
- 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.
- The trainee may not be assigned to call more often than every third night averaged over any consecutive four-week period.
Another related issue regarding the imposition of maximum hour policies for medical residents is the question of enforcement, where some enforcement proposals have included extending U.S. federal whistle-blower protection to medical residents in order to insure compliance and afford medical residents certain employment protection.
Effects on health
Effects of Limiting Duty Hours on Patient Morbidity and Morality
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. 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/she 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. 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.
Effects of Sleep Deprivation on Workers
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. Chronic sleep deprivation and the resulting fatigue and stress can affect job productivity and the incidence of workplace accidents. 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.
Experiments on Length of Shifts
In 2015 two controlled studies of the effect of the ACGME-mandated maximum shift were conducted, involving nearly 190 hospitals and residency training programs. The studies randomly assigned medical residents to shifts longer than specified by the ACGME regulations. A study led by the University of Pennsylvania, which will end in 2019, assigned residents in 32 medical training programs to shifts as long as 30 hours. It used 31 other programs as a control group. Despite the longer shifts, the other overall rules were still adhered to. The other study, led by Northwestern University and ending in 2015, was similar in design. Both were conducted with the approval of the ACGME. In neither study were residents and patients necessarily told they were part of a human subjects experiment and informed consent was not required.
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- 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
- Robert N. Wilkey, Federal Whistleblower Protection: A Means to Enforcing Maximum Hour Legislation for Medical Residents, William Mitchell Law Review, Vol. 30, Issue No. 1 (2003)
- Robert N. Wilkey, The Non-Negotiable Employment Contract - Diagnosing the Employment Rights of Medical Residents, Creighton Law Review, Volume 44, Page 705 (2011)