Statement of Dr. Michael Carome, Director, Public Citizen’s Health Research Group
Note: On Wednesday, the Accreditation Council for Graduate Medical Education (ACGME) is convening a two-day, invitation-only National Congress on Resident Duty Hours in the Learning and Working Environment in Chicago. This meeting is part of an effort that began late last year and is intended to revise the current ACGME rules on resident physician work hours, designed to prevent fatigue-related medical errors and to enhance resident health and well-being. With multiple physician groups lobbying against these safeguards, a likely outcome of this process could be the rollback of key elements of ACGME restrictions that were adopted in 2011 to protect both residents and their patients. Such an outcome would pose unacceptable dangers to residents and their patients.
Any effort to increase the number of consecutive hours resident physicians can work without sleep threatens the health of both residents and their patients, and should be rejected. Substantial evidence shows that sleep deprivation due to excessively long work shifts increases the risk of motor vehicle accidents, depression, and needle-stick and other injuries that can expose residents to bloodborne pathogens. Depriving medical residents of sleep also exposes their patients to an increased risk of medical errors, which can lead to patient injury and death.
The ACGME’s awareness of these known harms to residents and patients caused by excessively long physician resident work hours led it to tighten work-hour restrictions in 2011. The organization mandated a 16-consecutive-hour cap on shifts for first-year residents, a 28-consecutive-hour cap on shifts for all other residents and a minimum eight-hour time off between work shifts for all residents.
Those attacking the ACGME’s current resident work-hour restrictions argue that the limits actually increase medical errors by increasing the frequency of patient handoffs between medical residents. However, there is no valid evidence from well-designed studies to support these assertions. In fact, the most rigorous trial to-date of the effects of different work shift lengths found that reducing first-year residents’ shifts to 16 hours or less reduced the frequency of serious medical errors.
Of note, the ACGME provided funding for two clinical trials, known as the FIRST and iCOMPARE trials. These were designed to compare death and injury rates of patients cared for by residents randomly assigned to work shifts that comply with the current ACGME limits versus residents working longer hours (28 or more hours for first-year residents). These trials, conducted in hospitals throughout the country, are highly unethical, poorly designed and biased by the researchers’ desire to create evidence that can be used to support their underlying agenda to lift the ACGME’s 2011 protective limits.
Now is not the time to force residents to work longer hours. The ACGME instead should strengthen patient and medical resident safety by, among other measures, expanding the current16-consecutive-hour cap on work shifts for first-year residents to all residents.
To address concerns about problems related to patient handoffs, the ACGME should mandate new standards for ensuring that residents are trained on how to implement handoffs in a consistent, standardized and effective fashion and require that attending physicians supervise and confirm the adequacy of such handoffs.