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More Information on Medical Resident Work Hours

Letter on Medical Resident Duty Hours

August 1, 2002 

Jerry Vasilias, Ph.D.
Associate Director, Field Activities
Deputy Staff, ACGME Work Group on Resident Duty Hours
Accreditation Council for Graduate Medical Education
515 North State Street, Suite 2000
Chicago, IL 60610
Fax: (312) 464-4098

Dear Dr. Vasilias:

The major purpose of the ACGME’s proposed requirements for resident work hours is plain: to forestall both proposed legislation from the Congress and regulation from the Occupational Safety and Health Administration (OSHA), actions we have sought.  The ACGME, which is the accrediting body for U.S. residency programs, has produced a proposal that is riddled with loopholes (and even the loopholes have loopholes), provides no whistleblower protections and does not provide for public disclosure of violating hospitals.

But the underlying premise – that voluntary self-regulation is a reasonable response to the widespread abuse of residents – is the proposal’s major problem.  This is an industry that for years has turned its back on the mounting scientific evidence of the dangers of long work hours to patients and residents alike and has done little to address work schedules that have left the public scandalized.  It is only under the threat of action from the Congress and OSHA that it has actually been prodded into taking this problem seriously.

Attached you will find a table that summarizes the major work-hour reform proposals.  Even a cursory review shows that the ACGME proposal falls well short of both the legislation and petition and even short of the too-weak proposals offered (also under duress) by the Association of American Medical Colleges (AAMC) and the American Medical Association (AMA).  We now consider each element of the ACGME proposal in turn.

Diluted Hours Restrictions

Both the legislation and the petition clearly precludes any work weeks in excess of 80 hours.  The ACGME proposal appears, at first glance, to also require no more than an 80-hour week, but is in fact richly supplied with escape hatches for program directors wishing to continue business-as-usual.  First, the 80-hour restriction is really an 88-hour restriction, because programs can secure a 10% longer work week merely by assuring their Graduate Medical Education Committees that they have a “sound educational rationale” for an extension.  Second, the 24-hour shift restriction in the ACGME proposal is actually a 30-hour shift restriction, because six additional hours are allotted for “transfer of care, patient follow-up, and education.”  Third, the ACGME proposal permits work hours to be averaged over a four-week period.  Thus, scheduling three 70-hour weeks in a four-week cycle permits a week with a completely inappropriate 110 hours of work (of 168 hours in a week).  Permitting averaging for on-call frequency and mandatory off-duty time, as the ACGME proposal does, provides similar leeway.

Exemptions for Entire Specialties

Next the ACGME proposes to open the door to complete exemptions for entire specialties:

In the case that a specialty believes it cannot conduct its educational activities within the proposed constraints, an exemption beyond the 10 percent increase that can be granted by a sponsoring institution will require the approval of both the ACGME Program Requirements Committee and Board of Directors.  Such exemptions may be granted only if the specialty can demonstrate that there would be a significant detrimental effect on the clinical training and education. 

This is obviously unacceptable because it effectively guts the guidelines for the specialties that need them most.  It also provides no definition of what constitutes a “significant detrimental effect.”  Moreover, unless there are some data on the relative endurance capacities of the different specialists that have escaped our attention, there is no reason to think that long work hours will be any less dangerous to patients and doctors when required of one specialty than another.

Lack of Whistleblower Protections

Residency programs are typically not large and residents who complain about excessive hours are at risk for retaliation both from program directors and their fellow residents, who might fear that their program will lose accreditation.  However, the ACGME proposal, unlike the legislation and petition, fails to provide this basic protection for those residents courageous enough to bring dangerous infractions to public attention. 

No Public Disclosure of Violating Hospitals

Both patients and residents have a right to know which programs are most abusive and, conversely, those who best protect patient and worker health.  The ACGME appears to have little interest in having this potentially embarrassing program-specific information made public.  Professional associations seldom do.  But patients have a right to know where they are most likely to encounter an exhausted resident and residents have a right to select their residencies with all the work-hour data available to programs at their fingertips.

Inadequate Enforcement

As noted above, we have little confidence that the ACGME will firmly enforce its guidelines in the long run.  In part, this is because we have for years observed the shoddy enforcement of the current weak guidelines. 

The ACGME has used its enforcement data to claim that work hour violations are declining.  Through its Residency Review Committees (RRCs), the ACGME has developed a series of specific recommendations on housestaff hours for each specialty.  These can be very vague (the current limit for general surgery programs is whatever is considered “appropriate” by the residency program director) and are not enforceable by law.  In order to clarify the methods used to generate the aggregated (not program-specific) data published periodically by the ACGME, we contacted the ACGME in June, 2001.  Dr. Marvin Dunn, Director of RRC Activities for the ACGME, explained that the information in the aggregated data is “not a survey.”  Rather, it is based on citations for violating ACGME guidelines; these citations are a subset of violations, which are the actual data of interest.   “Peer judgment” is used to decide whether to cite a program, he said.  Such judgment depends on whether, in the reviewers’ opinions, the program is making efforts to change, how many violations there are, etc.  In many cases, violating programs are simply asked to provide a memo discussing how they will address the violations and are not cited, unless they are in violation at a follow-up visit, which can occur years later. These factors must be kept in mind when interpreting the ACGME’s claim that compliance with the current ACGME guidelines has improved.  In the absence of objective criteria for issuing citations, a decrease in reviewers’ tendency to cite violating programs is as likely an explanation for a decrease in citations as a decrease in the violations themselves.   Phrases like “excessive hours,” which appear elsewhere in the current ACGME guidelines, are also interpreted by what Dr. Dunn called “peer judgment.”

The only “stick” available to the ACGME is the threat of withdrawal of residency program accreditation, an ironic punishment of residents for being abused.  That is why more than one method of enforcing the work-hour restrictions is necessary.  With federal enforcement, civil monetary penalties could be used to bring violating programs into line without threatening the careers of those who have suffered most under the violative working conditions.

While the proposed ACGME guidelines do pay lip-service to improved enforcement, the irreducible fact is that the ACGME is better structured to narrowly represent its members’ interests than it is to forcefully police those members.  Both common sense and history argue that it would be so.  That is why federal intervention is necessary.

Conclusion

The ACGME’s proposal is a last-gasp effort to stave off federal intervention.  But it is unlikely to be adequately enforced and in any event is plagued by loopholes, exemptions and secrecy.  In the past, the ACGME has proved itself incapable of protecting patients and residents; if this grossly inadequate proposal is adopted, it will be proved so again. 

Yours sincerely,

Peter Lurie, M.D., M.P.H.
Deputy Director

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


The table below is also available in pdf format.

Comparison of Proposals to Limit Resident Work Hours

 

HR 3236 and
S 2614
 (1)

OSHA Petition(2)

ACGME(3)

AMA(4)

AAMC(5)

Entire Specialties Can be Exempted

No

No

Yes 6

No

No

Maximum Hours per Week

80 hours, no averaging

80 hours, no averaging

88 hours averaged over 4 weeks 7

84 hours averaged over 2 weeks 8

80 hours, no averaging

Maximum Shift Length

24 hours

24 hours

30 hours 9

30 hours9

24 hours

Minimum Time Off Between Shifts

10 hours

10 hours

10 hours

10 hours

8 hours

Maximum On-Call Frequency

Every third night, 
no averaging

Every third night, 
no averaging

Every third night, averaged over 4 weeks

Every third night, averaged over 2 weeks

Every third night, averaged over 4 weeks

Mandatory Off-Duty Time

24 hours off per week, 1 weekend off per month, no averaging

24 hours off per week, no averaging

24 hours off per week, averaged over 4 weeks

24 hours off per week, averaged over 2 weeks

24 hours off per week, no averaging

Whistleblower Protections

Yes

Yes

No

No

No

Enforcement

Civil penalties

Civil penalties

Voluntary approach10

Defers to ACGME

None mentioned 

Public Disclosure of Violating Hospitals

Yes

Yes

No

No

No

Provides for Additional Funding

Yes

Not applicable

No

No

No

 

1. http://thomas.loc.gov/;  Then type in the appropriate bill number.
2. http://citizen.org/Page.aspx?pid=614 
3. http://www.acgme.org/new/wkgreport602.pdf. Now available at: http://www.acgme.org/acWebsite/dutyHours/dh_wkgroupreport611.pdf.
4. http://www.ama-assn.org/ama1/upload/mm/annual02/RefcomC.Annot.doc. Now available at: http://web.archive.org/web/20060925112307/http://www.ama-assn.org/ama1/upload/mm/annual02/RefcomC.Annot.doc.
5. http://www.aamc.org/hlthcare/gmepolicy/gmepolicy.pdf. Now available at: http://www.aamc.org/patientcare/gmepolicy/gmepolicy.pdf.
6. If a specialty “believes it cannot conduct its educational activities within the proposed constraints,” it can apply to the ACGME for an exemption.
7. Individual programs may apply to their sponsoring institution’s Graduate Medical Education Committee for up to a 10% increase over the 80-hour limit if they can provide a “sound educational rationale.”
8. Under certain circumstances, a 5% increase over the 80-hour limit may be granted.
9. A 24-hour limit on in-house call duty, with an added period of up to 6 hours for transfer of patient care, educational debriefing and didactic activities.
10. The ACGME proposes voluntary enforcement of their guidelines by intensifying information collection, shortening residency review cycles, increasing their response time to alleged violations, and enhancing programs’ and institutions’ accountability for compliance.

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