ACGME gives final nod to 80-hour workweek

A major shift in physician training is under way, but how successful the transition will be remains to be seen.

By Myrle Croasdale, amednews staff. March 10, 2003.

July 1, 2003, will mark the dawn of a new era in physician training. On that day, all medical residents and fellows in all accredited training programs will be limited to an 80-hour workweek for the first time in the history of U.S. medical education.

The Accreditation Council for Graduate Medical Education approved new work-hour standards in June 2002 and issued a final version of the rules in February.

The rules
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With just a few months left to prepare, even ardent opponents are getting on board. Success is critical, since failure is sure to bring in government intervention.

Specialties such as internal medicine, pediatrics and family practice are ahead of the curve, having put duty-hour structures into place in recent years that closely mirror the new ACGME requirements.

Surgeons, however, have been among the last to get on board, arguing that capping their residents' 100-plus-hour workweeks would undermine their educational experience. They're already being jolted by the scheduling overhauls.

"Junior faculty and junior attendings are fearing for their lives," said Jeffrey Upperman, MD, junior faculty at Children's Hospital of Pittsburgh and an associate fellow of the American College of Surgeons.

Surgical residents often work more than 100 hours a week.

"The short-term solution is if residents can't take call, then the faculty will need to step in," he said. "If you're junior faculty with the pressure to publish or perish, that threatens your academic livelihood."

Junior surgical faculty have begun taking call at Children's, but Dr. Upperman said that's a temporary fix.

Hiring moonlighters or establishing a night float system are possible solutions, but Dr. Upperman also wants to see more support from hospital administrators. "We believe that the hospitals need to step up with safety systems and the manpower to help support the residents," he said.

Good-faith effort under way

Many resident programs are seeking extra staff to do some of the work previously done by residents.

Peter Watson, MD, resident trustee on the American Medical Association Board of Trustees and chief resident of internal medicine at Henry Ford Hospital in Detroit, said he's seeing this take place at his hospital, and he's hearing from other residents that this is happening across the country.

"My sense is there is a good-faith effort at teaching hospitals to comply with the new rules," he said.

64% of N.Y. teaching hospitals don't meet some part of the state's 80-hour workweek rule.

At Henry Ford, administrators are meeting with faculty and residents to discuss what work can be off-loaded from residents, what ancillary staff is needed and what safety systems will ensure that the increase in patient transfers won't be followed by an increase in medical errors.

Ingrid Philibert, director of field activities for the ACGME, said the medical profession is clearly concerned about compliance.

"Everyone understands if the community and the ACGME are not seen as doing a credible job, we will see federal intervention," she said.

Six months after the rules go into effect, the government will ask the ACGME for proof of compliance, and hospitals will have to provide documentation that they're meeting standards, Philibert said. Such data may be collected by computers via swipe cards or other systems that have yet to be devised, she said.

Doubts that the ACGME would wield real clout when it comes to enforcement were dispelled last year when it put the prestigious surgical program at Yale-New Haven Hospital on probation for violating current standards.

The ACGME's status as enforcer was also strengthened by the Occupational Safety and Health Administration, when in October 2002 OSHA rejected a petition asking for federal regulation of resident work hours. OSHA said the ACGME was in the best position to administer changes.

Those who question whether hospitals will comply have reason to be skeptical. In 1989 an 80-hour workweek became law in New York, but hospitals were slow to change.

In the most recent New York Dept. of Health report, 64% of teaching hospitals were found to be out of compliance with some component of work-hour regulations. Philibert said that's why the ACGME will use accreditation as an enforcement tool, not fines.

"Fines can never approximate the economic value of residents to a hospital. Fines don't scratch the surface," she said.

Evan Nadler, MD, a surgical fellow at Children's Hospital of Pittsburgh, began his training without work-hour restrictions in New York but finished it under the rules. He noted heavy compliance, but at a price.

"I think what is happening in New York will happen across the country," he said. "At the end of ... training, everyone will be as well trained, but it will take longer. It will take into your senior years to get enough experience to feel comfortable."

Dr. Nadler said he sees one significant difference between his experiences in Pennsylvania and New York.

"The nights I'm going home, I'm giving sign-outs directly to the attending," he said "In New York there are a lot of junior-level sign-outs, so you don't know if the quality is adequate."

Drs. Nadler and Upperman agree that while the ACGME can limit the hours residents work, there's nothing stopping other physicians from working more than 80 hours a week.

"We send Marines in to do bad things in bad places, and we rest comfortable knowing that we have that capability," Dr. Upperman said. "You ask any surgeon about the meaning of getting that phone call on Friday at 5 p.m. You know that once you're called to that floor, you will step up and do what's right and ignore the clock."

ADDITIONAL INFORMATION:

The rules

80 hours per week, averaged over four weeks. May increase by 10% in some circumstances.
One day off out of seven, averaged over four weeks.
No in-house call more than once every three nights, averaged over four weeks.
24 hours on call, maximum, with up to six additional hours to hand off patients and attend educational activities.
10 hours off between duty periods and after in-house call.
Probation or accreditation withdrawal for facilities that fail to comply.