Residency work hours: New rules, fresh vigilance

The ACGME's new work hour rules must be taken seriously by all involved.

Editorial. June 23, 2003.

There are some periods in life that are moaned and groaned through but remembered with great nostalgia -- even fondness -- once successfully survived. In the life of a physician, that period is medical residency, notorious for its intense workweeks that leave little time for sleep or social life.

In 1984, residency became infamous in the annals of patient safety as well, when the death of 18-year-old Libby Zion in a New York hospital focused the spotlight on the number of hours residents routinely worked and its effect on their judgment and effectiveness. The result of a grand jury investigation into Zion's death was a New York law passed in 1989 that set limits on the number of hours residents can work.

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Beginning July 1, teaching hospitals in the rest of the country will be operating under similar standards when the Accreditation Council for Graduate Medical Education's new resident work-hour rules go into effect. Every accredited teaching hospital in the nation will be required to follow the rules or face a threat to its accreditation status.

The rules call for residents to work no more than 80 hours a week, averaged over four weeks, and have one day off out of seven, averaged over four weeks. They also require a 24-hour limit of on-call duty with an additional six hours allowed for the transfer of patient care. Residents can have on-call duty no more than every third night, with at least one consecutive 24-hour duty-free period every seven days, averaged over four weeks.

The rules should effectively put an end to the worst of the grueling work shifts that have been a hallmark of medical training. They aren't likely to put an end to the debate over whether those shifts are necessary to quality medical education, but that is now a moot point. It is now time that academic medical centers make a good-faith effort to operate under the guidelines and that the ACGME take seriously its responsibility to make sure they do so.

The ACGME standards are largely in synch with AMA policies on resident work hours. At press time, the AMA House of Delegates was to consider several actions in support of enforcement, including activities with an eye towards how well the implementation of the new standards meets with actual practice.

New York hospitals have struggled to operate under the rules. The New York Dept. of Health recently reported that 64% of teaching hospitals were out of compliance with some part of the restrictions, reflecting a financially squeezed health care system that often has residents overloaded with work not directly related to their educational training.

It is important to note that if the profession does not police itself, it seems more and more likely that the federal government could step in. Measures were reintroduced in Congress this year, similar to the ACGME regulations. An AMA report, however, noted some problems with such an approach, including the difficulty of modifying such a law based on experience.

To doctors who have survived 110-hour workweeks during residency, 80 hours may seem like a walk in the park. But it is still twice as many hours as the standard workweek and comes in a era when cost concerns ensure that only the sickest patients are hospitalized. And the new standard should still give future residents much to moan and groan about while in the midst of it, hardships they can nostalgically recount later.