Peter Lurie, M.D., MPH, Deputy Director, Public Citizen’s Health Research Group
“Resident Duty Hours: Enhancing Sleep, Supervision, and Safety,” a report by an Institute of Medicine (IOM) committee released today, bends over backwards in its efforts to address the concerns of organized medicine and in so doing has foregone a golden opportunity to enhance patient safety. While concluding that “fatigue is an unsafe condition that contributes to reduced well-being for residents and increased errors and accidents,” the report still leaves monitoring of resident (doctors-in-training) work hours largely in the hands of the private Accreditation Council for Graduate Medical Education (ACGME), the professional association of residency programs, with decidedly minor roles for the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission. After decades of near-inaction, the ACGME finally produced voluntary work-hour guidelines in 2003, restricting residents to an average of 80 hours of work per week in most cases.
Giving the ACGME, a group with neither the appetite nor the ability to enforce significant work-hour reductions, the primary authority over resident work hours creates an irresolvable conflict of interest. Inevitably, the ACGME will bow to the financial concerns of health-care providers, potentially placing patients at risk from substandard medical care and the residents, themselves at risk for depression, needle sticks and car crashes while driving home after a grueling work shift – dangers the report acknowledges. Moreover, residents are unlikely to report violations of the ACGME guidelines, for to do so places their chances of graduating from an accredited program at risk. Nothing less than regulation of resident work schedules by a federal agency such as CMS can ensure that patient safety and resident education trump the economic benefits to healthcare providers of having residents work such long hours at salaries that would be modest even for 40-hour work weeks.
The report’s other significant recommendation is that residents working shifts longer than 16 hours be assured a five-hour period of “protected sleep.” The problems with this approach are legion. First, ACGME enforcement of the current guidelines has been lax and enforcing a guideline on sleep within shifts will be even more difficult. Second, in many instances the sleep will not be “protected,” as residents will be subject to various interruptions from hospital staff. (The report acknowledges that to date, compliance with such “protected sleep” policies has been “relatively poor.”) Third, research has shown that “protected sleep” programs have only a limited impact on total sleep time and no impact on objective measures of alertness and performance. In contrast, limiting shifts to 16 hours has been proven in a randomized, controlled trial to reduce serious medical errors. Fourth, while the report describes in some detail the dangers of “handoffs” between residents rotating on and off shift, the “protected sleep” proposal by definition will create two unnecessary handoffs, at the potential expense of patient safety.
The report also leaves intact the ACGME’s 80-hour work week limit and continues to permit this to be averaged over a four-week period, permitting, for example, three 70-hour weeks followed by a 110-hour week. It does, however, recommend that the ACGME no longer permit averaging in its restrictions on mandatory time off duty (one day off per week) and maximum on-call frequency (every third night). These “restrictions” still leave residents working shifts considerably longer than those in the maritime, trucking and aviation industries, as well as their medical counterparts in many industrialized countries.
The IOM report also downplays the concerns of patients. In a 2002 survey conducted by the National Sleep Foundation, 70 percent of respondents to a national public opinion poll reported that they were “somewhat likely” or “very likely” to request another doctor if they learned that their doctor had been working for 24 hours (the ACGME guidelines and the IOM committee recommendations permit 30-hour shifts).
The IOM report could have been a full-fledged endorsement of the potential to enhance patient safety through more evidence-based and enforceable work-hour restrictions. Instead, it has settled for minor policy adjustments that will not fundamentally alter the status quo, are unlikely to be enforced and are not well grounded in the scientific reports reviewed by the committee.