United States limits resident physicians to 80 hour working week

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United States limits resident physicians to 80 hour working week

Janice Hopkins Tanne New York

From 1 July 2003, the Accreditation Council on Graduate Medical Education will limit the work of the United States’s almost 100 000 resident physicians in 7800 programmes to 80 hours a week. Shifts are never to last more than 24 hours, and residents will have one day off in seven and get a 10 hour break between being on call and working a shift.

Resident groups and the consumer advocate group Public Citizen called the new rules deeply flawed. They say that they are unlikely to be adequately enforced, because they do not have the force of law. Some groups would like to see federal legislation introduced, but the last attempt to do so failed in the last session of Congress.

The issue of regulating junior doctors’ working hours goes back to the 1980s. After problems in New York city, a commission chaired by Dr Bertrand Bell, professor of medicine at Albert Einstein College of Medicine, recommended changes.

New York State has regulated hours since 1989 and uses a regulatory organisation to make surprise visits to hospitals to see if they are being observed. It also accepts anonymous tips about violations of work rules and fines hospitals that are overworking residents. Records of violations and fines are made public.

Puerto Rico enacted a law in January this year limiting residents’ hours, and the New Jersey state legislature is considering legislation.

In 2001 Public Citizen, the Committee of Interns and Residents, and the American Medical Student [note spelling; not students] Association petitioned the federal Occupational Safety and Health Administration to limit residents’ work but were turned down because groups such as the accreditation council were taking action.

The new rules improve things, said the Dr Marvin Dunn, director of residency review programmes at the accreditation council. Currently, each residency programme is reviewed at least once every five years by a committee with members appointed by the American Medical Association Council on Medical Education, the American Board of Medical Specialties, and often major specialty organisations.

Each residency programme submits a form describing the programme and the council sends a site surveyor to verify accuracy. A citation and probation system, with appeals, withdrew accreditation from 15 programmes of the 1920 reviewed in the past three years and put 61 programmes on probation. Dr Dunn says the system is "slow and deliberative" but will be speeded up, and a website will let residents make confidential complaints. "A law is not the most efficient way. It’s expensive and has rigid bureaucratic rules. If a profession doesn’t police itself, it loses its designation as a profession," Dr Dunn said.

Dr Bell, who chaired the New York state commission, said: "Graduate medical education is based on learning by mistakes: see one, do one, teach one . . . maybe kill one." To improve medical education, the issues are both residents’ hours and the quality of supervision. He said he expected little from a self regulating industry organisation and wanted government enforcement including jail time and fines for violations.

Dr Peter Lurie, deputy director of Public Citizen’s Health Research Group, called the rules "business as usual" and pointed to loopholes that could have residents working 88 hours instead of 80 and working 30 hours instead of 24.

Mark Levy, executive director of the Committee of Interns and Residents, noted that New York state enforcement improved after the state used an independent firm to make unannounced visits and implemented anonymous reporting of problems. "Residents tell me their lives have dramatically improved," he said.

Dr Eric Hodgson, president of the American Medical Student Association, said that because the new rules would be implemented by an industry group rather than an independent or government agency, enforcement was the weakest part. "Let’s see how it is in five years," he added.

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ACGME's 24 + 6 = 30 (!): Mark L. Levy; bmj.com, 4 Mar 2003 [Full text]

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