Activities

AMA - Resident and Fellow Section (RFS)
Report F (Interim Meeting-2001)

Subject: Resident/Fellow Work and Learning Environment 
Introduced by: Michael Suk, MD, JD, MPH, Chair

Introduction

This report will provide a brief update on the recent efforts made by the AMA-RFS and other groups to improve the working conditions for residents and fellows. The report will also give specific recommendations for new methods of evaluation and enforcement of resident and fellow work conditions.

Background

The issue of excessive resident/fellow work hours is not new. It is well known that for decades residents and fellows typically have been expected to work 70-130 hours each week in order to fulfill the clinical and educational requirements of their training program.

However, the problem is not just about excessive work hours but is about the totality of working conditions for residents. Simply limiting the number of hours residents work will not address the larger issues facing our health care system. Today’s health care system is under-resourced, under-staffed, and over-worked creating a sub-optimal working and learning environment for residents. Factors contributing to this environment include:

• Inadequate financial resources and severe nursing and ancillary staff shortages at hospitals. This often means residents have to perform numerous hours of tasks that neither advance their education nor require a physician.
• Hospital closures, cost-cutting by managed care organizations and an increasing number of uninsured patients resulting in decreased inpatient stays and increased patient turnover. This has led to a shift from learning to patient service.
• An increasing amount of required paperwork dramatically increasing the time spent by residents carrying out clerical and administrative duties.
• Out-dated beliefs that countless hours spent in the hospital are necessary to adequately train physicians and "toughen up" young doctors despite efforts to change these beliefs.

These factors have created an environment that makes limiting work hours only one of the steps necessary to improve resident working conditions and optimize patient care. Because residents are defined by the National Labor Relations Board as both students and employees, mandating work hours alone will not leave residents time for education. The future health of America depends on finding a balance between service and education. We must approach this issue with three thoughts in mind: (1) patient safety, (2) education for our young physicians, and (3) the well-being of residents.

Historically, the principal mode of regulation and enforcement of resident work hours has been through the Accreditation Council on Graduate Medical Education (ACGME). A major policy change by the American Medical Association (AMA) and the ACGME in the early 1990’s led to current ACGME guidelines that residents should, on average, have at least one in every seven days away from clinical duties and should be on call no more than every third night. In fact, many specialties have gone further, with call nights every four days and innovative shift relief systems known as nightfloats. Beyond ACGME regulations, in 1987 New York became the only state with regulations mandating work hour limits on residents. Nevertheless, more than 10 years after these regulations, an unannounced investigation conducted by the state’s Department of Public Health revealed that more than 37% of residents were required to work more hours than allowed by the regulations, and all of the programs reviewed violated some aspects of work hours standards.

Recent Activities

The complexity and severity of the issue of resident work hours has caused it to receive a great deal of attention in recent months as the AMA and other national resident and student organizations have made numerous efforts to find a solution:

OSHA Petition
In April 2001, the American Medical Student Association (AMSA), the Committee of Interns & Residents (CIR) and Public Citizen, filed a petition asking the Occupational Safety and Health Administration (OSHA) to enforce work hour standards for resident/fellows through its federal regulatory authority. This was based on the premise that excessive work hours posed a serious health risk to physicians in training much like other hazards in the workplace. Their petition outlines much of the data linking excessive duty hours for residents with potential harm among residents, including motor vehicle accidents, declines in mental health, and pregnancy complications. Finally, the petition emphasizes the potential connection between excessive resident work hours and patient safety and medical errors. The petitioners asked OSHA to consider enforcing the following work hours limits:

• A limit of 80 hour work per week.
• A limit of 24 consecutive hours worked in one shift
• A limit of on call shifts to every third night
• At least one 24 hour period off duty per week

This is the first time a federal regulatory body has been asked to evaluate this issue. Although it is not clear whether OSHA will exercise its authority in this area, the action has raised awareness of the work hour’s debate.

Federal Legislation: The Patient and Physician Safety and Protection Act of 2001(H.R 3236)
In November of 2001, Congressman John Conyers, Jr. (D-Michigan), in collaboration with the American Medical Student Association (AMSA), introduced H.R. 3236, "The Patient and Physician Safety and Protection Act of 2001," to the House of Representatives Committee on Energy and Commerce and Committee on Ways and Means. The legislation would amend title XVIII of the Social Security Act to reduce the work hours and increase the supervision of residents to ensure the patient and physician safety. As a condition of participation in Medicare, the legislation would require hospitals to establish the following limits on work hours for residents:

• Residents would not be allowed to work more than 80 hours per week, or 24 hours per shift.
• Residents would have at least 10 hours between scheduled shifts.
• Residents would have one full day out of every seven days off and one full weekend off per month.
• Residents assigned to the emergency department would work no more than 12 continuous hours.
• Residents would not be on call more than every third night.

AMA-RFS/CIR-SEIU Exploratory Meeting
On August 18, 2001, the AMA Resident and Fellow Section (AMA-RFS) convened a National Resident Work Hours Exploratory Meeting in Washington, DC. The meeting was co-sponsored by the Committee of Interns and Residents (CIR/SEIU). This unprecedented event brought together 42 resident and medical student leaders, representing 14 organizations including 12 specialty societies to explore opportunities for collaboration to address the problem of resident working conditions.

The group engaged in a process designed to build relationships and allow participants to identify common goals, reasons to work together, obstacles to overcome, and a plan of action. Resident and student leaders realize that this problem cannot be solved by any one organization and that by working together, we would increase resources, raise the profile of the discussion, and lay the foundation for future efforts. It was noted, however, that we would face several challenges in our effort to work together since our respective organizations would be forced to overcome philosophical differences and histories of conflict, both within their parent organizations and among other groups.

ACGME Work Group on Duty Hours and Learning Environment
At its September meeting, the ACGME resolved to form a work group to address the issue of resident duty hours in the context of a greater learning and working environment for residents. The charge of this group is to better define the problem with the hope of developing more standard requirements for resident duty hours across specialties. In addition, the work group is charged with formulating the ACGME’s response to regulatory and legislative proposals concerning duty hours.

AMA/AASM Sleep Conference
The AMA Council on Medical Education and the American Academy of Sleep Medicine cosponsored a workshop on "Sleep, Fatigue, and Medical Training; Optimizing Learning and the Patient Care Environment" on October 28-29, 2001 in Washington, DC. The workshop was designed to provide a diverse group of invested professional and public organizations a forum to present scientific information, share experiences and approaches, and begin a more formal interdisciplinary dialogue on this important and timely topic. Participants included national experts in the fields of sleep medicine, medical education, patient safety, residency groups, hospital administration, medical ethics, government, and transportation professionals.

AMA-Resident and Fellow Section Position

Resident work hours has been a high-priority issue for the RFS for over 25 years. The AMA has always stated that this issue should be addressed "without regulation by agencies of government" (AMA Policy H-310.979, Resident Physician Working Hours and Supervision)   and has instead relied traditionally on the ACGME to enforce current work hour standards. Although the RFS has traditionally supported intervention by ACGME, it is becoming increasingly clear that ACGME may not be able to adequately enforce the Residency Review Committees’ work hour standards. At its annual meeting in June, the RFS Assembly adopted Governing Council Report F that asked the AMA to take a more comprehensive approach to resident working conditions. The time has come for the AMA to explore other options to address this problem. Given the complexity of this issue, the RFS recognizes that no one organization or strategy will prove successful in finding a solution.

To appropriately address the issue of resident work conditions it will require a multi-faceted approach based on collaborative efforts with other medical organizations. These approaches should be based on the following principles: (1) to achieve an appropriate balance between education and service and; (2) to ensure that reporting mechanisms hold institutions primarily accountable for work conditions, rather than individual residency programs.

Recommendations

Recommendations as adopted by the RFS and MSS Assemblies at I-01:

1. That the AMA may draft original, modify existing, or oppose legislation and pursue regulatory or administrative strategies when dealing with resident work hours and conditions.
2. That the AMA continue to work with organizations like the Accreditation Council on Graduate Medical Education (ACGME) and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) toward finding solutions to the problem of work hours and conditions which would strengthen current work hours enforcement mechanisms.
3. That the AMA encourage the Agency for Healthcare Research and Quality (AHRQ) to examine the link between resident work hours and patients safety and to explore possible solutions to the problem of work hours and conditions.
4. That these recommendations be forwarded to the House of Delegates at I-01.