December 23rd, 2008
Ever since an 18-year-old New York woman died tragically in 1984 under the care of medical residents who—in the view of her family—were overworked and undersupervised, the subject of the duty hours of physician trainees has simmered in the academic medical community and, on occasion, among public policymakers. Now, as the consequence of a new study by the Institute of Medicine (IOM), these issues will reemerge in a robust fashion again, and the leading questions will focus on how to ensure patient safety while maintaining rigorous training programs.
The IOM study was requested by four members of Congress—all of whom are senior members of the House Energy and Commerce Committee—as part of the panel’s investigation into preventable medical errors. They are Chairman John Dingell (D-MI), ranking Republican Joe Barton of Texas, Rep. Bart Stupak (D-MI), and Rep. Ed Whitfield (R-KY). In a letter (dated March 29, 2007), the representatives directed the Agency for Healthcare Research and Quality (AHRQ) to contract with the IOM to study “medical errors associated with physician and resident work schedules.”
In particular, the legislators said their interest in the subject “was recently heightened” by a study funded by AHRQ and published in PLoS Medicine that “found medical errors resulting in adverse events, including death, due to sleep-deprived and over-extended medical residents and interns, substantiating previously held concerns about physician work schedules.”
Some background. Before highlighting the key recommendations of the IOM report and early reactions to it, a bit of background may be helpful. Following the death of Libby Zion in a large New York City teaching hospital, a grand jury did not charge any of the accused residents but concluded that their long duty hours were counterproductive to both patient care and resident learning. Subsequently a commission formed by New York state recommended, and in 1989 the state adopted, a requirement that residents work no more than 80 hours a week, averaged over four weeks. In 2003, the Accreditation Council for Graduate Medical Education (ACGME), which accredits some 8,500 U.S. medical residency training programs, promulgated national requirements that limited the work week of residents to an average of 80 hours a week.
About five years after the ACGME imposed these limits, the IOM issued its report (on December 2, 2008) that recommended further measures be taken to ensure that hospitals provide safer conditions for patients and trainees while maintaining teaching programs of high quality. Among many recommendations, which I also summarized in a New England Journal of Medicine Perspective, the report said new measures should be adopted to alleviate fatigue and loss of sleep among trainees, that residents should be more closely supervised by senior physicians, that more effective hand-offs of patients between residents and other doctors should be developed, and that a federal agency [the Centers for Medicare and Medicaid Services (CMS)] and a private not-for-profit organization (the Joint Commission on Accreditation of Healthcare Organizations, which was recently rebranded as the Joint Commission) should monitor how effectively the ACGME enforces the duty-hour rules.
IOM recommends 5 hours of uninterrupted sleep. Among its many recommendations, the IOM report urged that the current limit of an 80-hour workweek, averaged over 4 weeks, be maintained and that duty periods running longer than 16 hours be required to include a 5-hour uninterrupted period of continuous sleep between 10 p.m. and 8 a.m., during which residents would be free from all work.
Hot debate. In the three weeks since the report was released, the New England Journal of Medicine has published reactions to the IOM report from medical interns, residents, senior doctors, and others on its Web site (the commenting period is open through December 24). The opinions expressed underscore the wide range of views that surround duty-hour requirements, the recommendations of the IOM, and the challenge of striking the inevitable compromises that must be forged between the conflicting priorities of the affected stakeholders.
A New York medical student, Amar Bansal, noted some of these conflicting forces that make finding solutions difficult. He identified the fragmenting of care as shifts decrease in length, the possibility that shorter work weeks may require long residency training periods, the disdainful view of “old guard” physicians who trained without duty-hour limits, and the “real possibility” of creating an “unprofessional and unionized fleet of new physicians who view their time in the hospital as defined by a quota.”
Among medical specialties, the surgical community is the most exercised over the recommendation that a trainee’s duty hours would be abbreviated by a requirement that five hours of uninterrupted sleep be part of his regimen. Dr. George Chiang, who practices at Children’s Hospital in San Diego, wrote:
Since I finished by 6-year residency in 2007, I have seen life with and without an 80-hour limit. As a surgeon, I have not seen a change in outcomes, but I have seen a dramatic change in the work ethic and diligence of residents. . . . We are not pilots. We do not take care of patients according to a schedule or daily planner. We are at the bedside or in the OR [operating room] or scrutinizing labs at all hours of the day and night. Residency is not only about improving patient health but it’s also about handling stress and fatigue and being capable of making the right decision at all times.
Given the range of opinions that encircle the issues around the duty hours of residents, it was clear even before the study was completed and released that the recommendations of the IOM committee would not be embraced in whole by any interest. While the surgeons lamented the call for a more stringent set of limits on duty hours, the American Medical Student Association, the Committee of Interns and Residents (which is affiliated with the Services Employers International Union), and Public Citizen all favored even tighter restrictions on the hours worked by trainees.
Enforcing the rules. I did not see one comment that criticized the IOM’s call for the monitoring of the effectiveness of the ACGME’s enforcement of its residency hour rules by the CMS or the Joint Commission, suggesting perhaps that its enforcment efforts could be strengthened. But at the same time, early reaction from Capitol Hill has not suggested that Congress should step in and, through legislation, turn over responsibility for accrediting residency programs and the enforcement of residents’ duty hours to the federal government. Although the report has barely landed on the desks of the legislators who requested it, I suspect they will find themselves consumed by other matters deemed more pressing in the 111th Congress, although the House committee that directed the study be done may hold a hearing to take testimony on it.
Hour limits in other countries. One of the more interesting dimensions of the IOM’s study is an appendix that reports on the ongoing efforts of some other countries to reduce the duty hours of their residents. For most of the countries examined by the IOM committee (Australia, the Canadian provinces of British Columbia and Manitoba, Denmark, France, New Zealand, and the United Kingdom), the primary reason presented for modification of total resident hours was worker, not patient, safety.
Each country has experienced difficulties implementing its intended reductions due to workforce shortages, and some have faced strains on educational training, including reduced contact with patients. Residents in Europe who train under collective agreements struck by the European Commission are limited to a maximum work week of 48 hours. Residents in Denmark work a 37-hour week, although some take part-time jobs in other venues to supplement their incomes. In the United Kingdom, residents work 56-64 hours, depending upon the specialty, but that country is seriously considering lowering the weekly maxium to that established by the European Commission—48 hours.Email This Post Print This Post
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