Sept. 2, 2010
OSHA Should Regulate Work Hours for Doctors-in-Training, Groups Tell Labor Department
Medical Residents Need Shorter Shifts, Enforced Policies to Protect Themselves and Patients
WASHINGTON, D.C. – The Occupational Safety and Health Administration (OSHA), which is tasked with enforcing safety and health legislation, should take doctors-in-training under its purview, consumer and health advocacy groups said today in a petition sent to the agency.
Resident physicians work shifts as long as 30 hours as often as three times a week, which can lead to physician fatigue and medical errors. Exhausted resident physicians are at increased risk of being in a car crash and suffering from depression, pregnancy complications and needle sticks, research shows.
Because OSHA, which is part of the Department of Labor, is supposed to ensure the safety and health of workers, it has jurisdiction over resident physicians and should protect them, the groups said. Those petitioning OSHA include: Public Citizen; the Committee of Interns and Residents/SEIU Healthcare; the American Medical Student Association; Dr. Charles Czeisler, Baldino professor of sleep medicine and director of the division of sleep medicine at Harvard Medical School; Dr. Christopher Landrigan, assistant professor of pediatrics and medicine at Harvard Medical School; and Dr. Bertrand Bell, professor of medicine at Albert Einstein College of Medicine.
Currently, the Accreditation Council for Graduate Medical Education (ACGME), the nonprofit organization that oversees training programs for resident physicians, is responsible for regulating and enforcing resident physician work hours. In July, it proposed new guidelines for work hours for resident doctors, but they still leave the majority of those doctors in danger, the groups said.
“In the past, Public Citizen has successfully petitioned OSHA to protect workers by lowering the allowable workplace levels of various toxic exposures, such as hexavalent chromium, ethylene oxide, benzene and cadmium. The dangerously excessive number of hours resident physicians are currently allowed to work is a similarly toxic exposure that OSHA has the authority to regulate and reduce in order to protect these physicians from harm,” said Dr. Sidney Wolfe, director of Public Citizen’s Health Research Group. “This is especially urgent since the current private-sector regulating organization, ACGME, has continued to abdicate its responsibility to adequately protect resident physicians.”
The federal government already regulates work hours and sets rest-period requirements in a variety of industries, including the highway, aviation, railroad and maritime transportation industries, because fatigue plays a major role in transportation safety. In none of these industries are workers allowed to work hours even remotely as long as these physicians. Resident physicians should have similar protections from excessive work hours that don’t give them adequate rest, the groups said.
Other countries, such as Denmark, New Zealand and the United Kingdom, regulate resident physician work hours – and all of these countries limit shifts to less than 16 hours or fewer for all resident physicians and limit the work week to fewer hours than the ACGME is proposing.
“Based on what we have learned from research evidence, we don’t recommend that any physician stay awake for 24 hours or more, which is the case today,” said CIR/SEIU Healthcare President Dr. Farbod Raiszadeh. “OSHA must intervene so that physicians in training are no longer at risk for needle stick injuries, car crashes and other hazards that we know stem from chronic sleep deprivation.”
A survey published in the Journal of the American Medical Association found that six of seven surgical resident physicians had fallen asleep at the wheel while driving to and from work. Three of these six residents had been involved in car crashes.
“After a busy night on call, I remember a couple of times when I literally fell asleep on my patients standing up during morning rounds,” said Dr. Charles Preston, a researcher with Public Citizen’s Health Research Group and preventive medicine resident at Johns Hopkins School of Public Health. “I'd fall asleep while writing my patient progress notes. And driving home, I was careful to turn up the radio or blast the air conditioning so that I would at least have something more to keep me awake. Residents need OSHA to protect them because no one else will.”
Resident physicians also are at high risk of developing clinical depression. As many as 30 percent of resident physicians experience depression at one time during their residencies. Female residents are especially vulnerable.
“As future physicians, we greatly value the well-being of our patients and know that we can serve them better if we are well ourselves,” said Sonia Lazreg, health justice fellow with the American Medical Student Association (AMSA). “Instead, I have seen relationships fall apart, watched residents alternately scream at patients then cry through exhaustion, and heard friends tell years-old traumatic stories about the death of a patient that still lingers without being properly grieved. Unnecessarily excessive work hours contribute to major depression and thwart any opportunity to seek counseling or other supportive services that would return our humanity. AMSA implores OSHA to step up and fulfill its mission, instituting medical work-hour regulations that will keep us all safe.”
Additional research shows that:
• Because of acute sleep deprivation, female resident physicians who become pregnant while working as resident physicians may face an increased risk of premature labor requiring bed rest; high blood pressure and seizures during pregnancy; pre-term delivery and low birth weights for infants born during residency. Nearly half of married female resident physicians will become pregnant during their residency.
• Resident physicians face an increased risk of serious needle stick injuries during day shifts after working for more than 20 consecutive hours compared to day shifts when they were working shifts that average fewer than 12 hours in duration. Needle stick injuries potentially expose resident physicians to HIV, hepatitis C or other infectious diseases.
“Besides endangering patients in teaching hospitals, exposing more than 80,000 resident physicians to such hazardous working conditions for years during their employment increases their risk of harming themselves,” said Czeisler, one of the petition signers. “Given the failure of the medical profession to protect the health and safety of these young doctors, we are urging OSHA to set appropriate work-hour limits that eliminate the marathon shifts that endanger resident physicians and their patients.”
Added Bell, who authored the New York state health code restricting resident physician work hours, “It has been 26 years since these rules were first promulgated and were made a part of the health code of New York state. The fact that they are not enforced means that the state is breaking its own laws.”
The groups are urging OSHA to implement and enforce the following regulations:
• A limit of 80 hours of work per week, without averaging (current rules allow for averaging, meaning that resident physicians may work 100 hours one week and 60 hours the next);
• A limit of 16 hours worked in one shift for all resident physicians (the ACGME’s proposed guidelines limit the length of shifts to 16 hours only for first-year residents, also known as interns);
• At least one 24-hour period of off-duty time per week and one 48-hour period per month, for a total of five days off per month;
• In-hospital on-call frequency no more than once every three nights, without averaging;
• At least 10 hours free between duty periods; and
• No more than four consecutive night shifts and 48 hours off after working three or four of these.
The petition signers ask OSHA to strictly enforce the requested policies by requiring resident physician and fellow schedules to be recorded and kept as public records by the hospitals, implementing an official and confidential procedure for whistleblowers to report violations to OSHA, inspecting hospitals frequently and unannounced, and creating sufficient fines for violating the policies.
To see more of the coalition’s work, visit www.WakeUpDoctor.org.