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More Information on Medical Resident Work Hours

Petition to Reduce Medical Resident Work Hours

September 2, 2010

PART 7: REQUESTS

Petitioners' Requests

Public Citizen, the Committee of Interns and Residents/SEIU Healthcare, the American Medical Student Association, Dr. Bertrand Bell, Dr. Charles Czeisler, Dr. Christopher Landrigan, and other petitioners request that the following hours-of-service regulations be applied to resident physicians in all residency and subspecialty fellowship programs:

(1)   A limit of 80 hours of work in each and every week, without averaging;

(2)   A limit of 16 consecutive hours worked in one shift for all resident physicians and subspecialty resident physicians;

(3)   At least one 24-hour period of time off of work per week (no averaging) and one 48-hour period of time off of work per month (no averaging);

(4)   In-hospital on-call frequency no more than once every three nights, no averaging;

(5)   A minimum of at least 10 hours off work after a day shift, and a minimum of 12 hours off work after a night shift;

(6)   A maximum of four consecutive night shifts with a minimum of 48 hours off after a sequence of three or four night shifts.

Work hours should be measured as time at the work-site; time asleep at the work-site should be counted as work hours. Time off work should be measured as time away from the hospital while not on-call. The regulations shall not be construed to require or permit a resident physician to abandon his or her patient in need of emergency or critical care. In an extreme situation proven by the hospital to be a patient-care emergency, and when that resident physician cannot be replaced by a rested resident physician, or his or her skills are not replaceable, the resident physician’s or subspecialty resident physician’s work that day may exceed the maximum 16-consecutive-hour shift or 80-hour per week limit in order to complete that patient’s emergency care. This does not mean that resident physicians may be scheduled to be present at a work‑site in excess of the 16-hour-per-day or 80-hour-per-week limit, or that new patients may be assigned at or near the end of that time.

These requested rules differ from the 2011 ACGME proposal in several ways. First, whereas the most recent ACGME rules call for an 80-hour work week averaged over a four-week period, the signers of this petition are calling for an 80-hour work week that is not averaged. The signers believe that two 100-hour weeks and two 60-hour weeks are not consistent with minimizing harm to physicians and patients, and that exceptions to an 80-hour week should not be granted to any residency programs. The ACGME suggests exemptions allowing certain residencies to exceed 80 hours of work per week. As stated previously, we believe the same standard should apply to all specialties, as they are based on human biological limits, not particular specialty-based functions. We suspect that many surgical programs, long known for their vigorous opposition to work-hour restrictions, will want to seek work week exceptions. We therefore request an 80-hour limit of work per week be applied to all residency and subspecialty fellowship programs, across specialties. Second, the ACGME rules call for a maximum continuous shift time of 16 hours for interns, but they allow for intermediate and senior resident physicians to work up to 28 hours. The differential treatment makes no sense, since all resident physicians are at risk of harming themselves and patients. In the Levine et al. systematic review cited above, intermediate-level and higher resident physicians, as well as interns, were found to provide better care when shifts exceeding 16 hours were eliminated. Third, the ACGME proposal provides for one day off per week, averaged over four weeks. Again, working two continuous weeks, at such an intense pace, is not consistent with minimizing fatigue. Fourth, in-hospital on-call frequency should be no more than every third night without averaging, for all resident physicians. The ACGME proposal seems to suggest that this would only apply to intermediate and senior-level resident physicians, but not to interns. Even if resident physicians were working no more than 16-hour on-call shifts, there should not be any rule that allows them to work on-call more often than this, which would greatly increase the risk of excessive fatigue. Fifth, as recommended by the Institute of Medicine, resident physicians should get a minimum of 10 hours off work after a daytime work shift, and 12 hours off work after a night shift. This is necessary to allow for adequate sleep time that will prevent the build-up of sleep debt over time that results from chronic sleep restriction. The ACGME proposal requires only eight hours off work between shifts, which would lead to inadequate sleep on a regular basis, once commuting time and personal responsibilities are accounted for. Finally, the ACGME should follow the recommendations of the IOM and prohibit resident physicians from working more than four consecutive night shifts, and following three to four consecutive nights of work, a 48-hour period free of work should be provided to allow for recovery sleep and prevent the buildup of sleep debt. The current ACGME proposal allows for resident physicians to work six night shifts in a row, a number demonstrated to lead to an increased risk of accidents and errors.[1]

Enforcement

Furthermore, the signers of this petition request that strict enforcement accompany the regulations, as inadequate enforcement policies have been a source of failure in previous efforts to limit resident physician work hours:

(1)   Resident physician and subspecialty resident physician schedules should be recorded and kept as public records by the hospitals, available for OSHA inspection;

(2)   There must be an official and confidential procedure for whistleblowers to report violations to OSHA;

(3)   Unannounced inspections should occur on a frequent basis;

(4)   OSHA must establish enforcement mechanisms so that violations incur fines sufficient to deter those violations.

Conclusion

Evidence convincingly demonstrates that excessive work schedules risk resident physicians’ lives and health, in terms of automobile safety, mental health, pregnancy complications, and percutaneous injuries. OSHA can readily adopt the standards requested in this petition, which are based on an expansion of those put forth by the ACGME. ACGME has failed to demonstrate that it can enforce tighter work-hour rules on its own.

After establishing the requested regulations, as a second, necessary step, OSHA should then proceed to investigate resident physician work hours more thoroughly to determine if even stricter standards are required. As elegantly defined in its enabling legislation,[2] the Occupational Safety and Health Act of 1970, OSHA’s mission is to “assure so far as possible every working man and woman in the Nation safe and healthful working conditions.”[3] The signers of this petition believe that OSHA should immediately establish the requested work‑hour regulations for resident physicians and subspecialty resident physicians to fulfill this mission.

Charles M. Preston, M.D., M.P.H.
Preventive Medicine Resident Physician
Johns Hopkins School of Public Health
Researcher
Public Citizen’s Health Research Group

Sidney M. Wolfe, M.D.
Director
Public Citizen’s Health Research Group

Charles A. Czeisler, Ph.D., M.D.
Baldino Professor of Sleep Medicine
Harvard Medical School

Christopher P. Landrigan, M.D., M.P.H.
Assistant Professor of Pediatrics and Medicine
Harvard Medical School

Farbod Raiszadeh, M.D., Ph.D.
President
Committee of Interns and Residents/SEIU Healthcare

American Medical Students Association (AMSA)

Bertrand Bell, M.D.
Professor of Medicine
Albert Einstein College of Medicine


[1] Folkard S, Lombardi DA. Modeling the impact of the components of long work hours on injuries and "accidents". Am J Ind Med 2006.

[2] P.L. 91‑596

[3] Occupational Safety and Health Administration. OSHA Strategic Plan. http://www.osha.gov/oshinfo/strategic/pg1.html#intro

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