Petition asks OSHA to limit resident work hours

The AMA seeks voluntary compliance with standards created by the Accreditation Council for Graduate Medical Education rather than government intervention.

By Jay Greene, amednews staff. May 21, 2001.

Medical education experts agree that residency training should balance work with education to produce competent and caring physicians. But as teaching hospitals cut support staff and treat sicker patients requiring more care, residents often find that balance shifting toward the work end of the equation.

For the last 10 years the medical community has debated how to ensure that residents aren't working so many hours that their ability to provide quality care is diminished. The Accreditation Council for Graduate Medical Education, the body that accredits the nation's 7,600 residency programs, has taken steps within some specialties to discourage long work hours and ensure residents have sufficient rest and educational time.

"The ask"

But more than 10% of residency programs surveyed in 1999 -- or 243 of 2,078 in 27 specialties -- violated work hour compliance standards, most of which have been in place less than 10 years, said ACGME. Citations for duty hour standards have been increasing over the last three years, ACGME said. However, the council's only penalty for noncompliance is removal of accreditation -- a punishment it has yet to wield.

Given the number of violations and the lack of enforcement tools, it's not surprising that some medical students and residents are now calling for federal regulation of work hours.

Is federal regulation the answer?

In a petition filed last month with the Occupational Safety and Health Administration, three consumer and physician advocacy groups decided to seek federal regulations that would limit work hours for residents and fellows. The six-point guidelines include limiting hours to an average of 80 per week. The petition states that some residents work between 60 and 135 hours a week.

"We took this route because the ACGME, through their track record, has been unable to take care of the problem. We need federal regulation," said Peter Lurie, MD, deputy director of health research with Public Citizen, one of the petitioners. The two other groups are the Committee of Interns and Residents, a resident and fellow union in New York, and the American Medical Student Assn.

"This is a health and safety question and we believe OSHA should act on this petition," Dr. Lurie said. "This is blazing new ground for them."

But an OSHA spokesman said the agency has no jurisdiction over work hours and that the Employment Standards Administration, wage and hour division, is the appropriate agency to hear the petition. OSHA will officially respond to the petition "in a timely manner," the spokesman said.

Government jurisdiction uncertainty aside, Liana Puscas, MD, AMA resident trustee and surgical resident at the University of Southern California, Los Angeles, said the petition has raised the stakes in the ongoing debate to balance work and education.

"Studies on airline pilots and truck drivers clearly show that there is impairment after long hours of work with no sleep," Dr. Puscas said.

"But the studies haven't shown that long work hours affect patient care or result in medical errors. We feel the best way to keep work hours appropriate is through compliance with ACGME regulations and a cultural shift in thinking about this issue within medicine," she said.

But the petitioners also contend sleepy and overworked residents make medical errors and cite studies showing that sleep-deprived physicians-in-training are at increased risk of being in an auto crash, having depression and giving birth to premature infants. Few studies, however, have been conducted that specifically link medical errors with overworked and fatigued residents.

One study cited in the petition and published in 1991 in the Journal of the American Medical Association found that 41% of 145 residents surveyed cited fatigue as a cause of their most serious mistake. In nearly one-third of these cases, the patient died as a result of the error, according to the study, "Do House Officers Learn from Their Mistakes?"

"These are grave health outcomes and any system allowing its workers to be subjected to such direct threats to their well-being is seriously flawed," stated the petition. "For OSHA not to regulate resident work hours is to abdicate its responsibility to protect the health of those who care for the nation's sick and dying."

But Dr. Puscas said voluntary compliance through ACGME is the way to go. "If support systems within teaching hospitals are not in place for residents, regulations may backfire on patients." For example, patients could find themselves with fewer health care workers available to them if residents adhered to strict work schedules, she said.

Effects of sleep loss to be studied

To address resident work hour issues, the AMA plans to hold a joint conference with the American Academy of Sleep Medicine. The conference, which will explore problems associated with sleep deprivation on medical education and physician performance, is tentatively scheduled for April 2002.

Federal legislation to limit resident work hours also could be introduced next month, a spokesman with the medical student association said. The AMA opposes such legislation, and currently New York is the only state with resident work hour laws. State law limits residents to an average of 80 hours per week over a four-week period. Residents also may not work more than 24 consecutive hours.

Over the past 15 years, six countries have limited average weekly work hours to address problems related to overworked residents. Australia limits hours to 70 a week, Denmark requires fewer than 45 hours, the United Kingdom and Germany set the bar at 56 hours or less and the Netherlands is at 48 hours. The European Union will require residents work less than 48 hours by 2003.

ADDITIONAL INFORMATION:

"The ask"

A petition filed with the Occupational Safety and Health Administration asks the agency to lighten resident schedules by:

Limiting hours to 80 per week.
Limiting work to 24 consecutive hours in one shift.
Limiting on-call shifts to every third night.
Providing a minimum 10 hours off-duty time between shifts.
Giving at least one 24-hour period of off-duty time per week.
Limiting a day's duty to 12 consecutive hours for emergency medicine residents working in hospitals that receive more than 15,000 unscheduled patient visits per year.

Source: Public Citizen, Committee on Interns and Residents and the American Medical Student Assn.