ACGME's Latest Rule Change on Resident Duty Hours Stirs a Long-Simmering Debate
Education Feature — April 2017
Tex Med. 2017;113(4):45-49.
By Sean Price
It's no secret that medical residents work long, sometimes crazy hours.
"There are definitely times after I'm up all night and it's getting into the next morning when I feel exhausted," said Lauren Zammerilla, MD, a second-year plastic surgery resident at Parkland Memorial Hospital in Dallas. "You wish you could go home, but you can't because there are not enough people to do the work. The patients have to come first."
Since the 1980s, concerns about resident fatigue have caused lawmakers and medical policymakers to pull back on resident duty hours. In 2003 and again in 2011, the Accreditation Council for Graduate Medical Education (ACGME) — the private group that oversees physician training — shortened resident hours. For instance, most first-year residents cannot work longer than a 16-hour day, and they must get at least one day of rest per week averaged over a four-week period. Also, their total duty hours cannot exceed 80 hours per week.
In March, though, ACGME modified those hours again. Under the new rules, all residents:
- Will be allowed to work a 24-hour day (which could be extended to 28 hours in "rare circumstances");
- Must have at least 14 hours off after shifts of up to 24 hours; and
- Will be allowed to work more than six consecutive night shifts.
Residents will still work up to 80 hours a week averaged over four weeks. They also will still get a mandatory day of rest per week. ACGME's move came on the heels of recent studies showing general surgery residents are more satisfied about patient safety and continuity of care when they have more flexible duty hours.
These developments have reignited a long-running argument between two camps in the medical world. One side argues sleep-deprived residents are in no position to make life-or-death decisions. The other argues curtailed resident hours hurt medical training, contribute to a shift-oriented mentality among young physicians, and shortchange patients.
"It's an ongoing debate," says Jonathan MacClements, MD, assistant dean for graduate medical education for The University of Texas Dell Medical School at Austin. Dr. MacClements is the "designated institutional official" who oversees Dell's compliance with the ACGME requirements. He says the debate involves two important questions: "Is it better to have a well-rested resident who hands over cases more frequently with the potential of perhaps not fully educating the oncoming team about the patient's care? Or is it better to have the resident work longer with a full knowledge of the patient and all the subtleties that entails?"
Fallout From the Zion Case
Modern medical training in the United States has always been rigorous and time-consuming. In the mid-1900s, young doctors actually lived at the hospital while they did their training — a practice that gave medicine the terms "house staff" and "resident." Many residents worked more than 100 hours a week, at times for 36 hours without rest.
Some doctors still have fond memories of those grueling residencies. "That was probably cruel and unusual punishment," said Kenneth Mattox, MD, who is now a professor at Baylor College of Medicine in Houston and chief of staff and surgeon-in-chief at Ben Taub Hospital, where he's worked since 1973. "I didn't think I was hurt by it. I rather enjoyed it."
The controversy over resident hours erupted in 1984 with the case of 18-year-old Libby Zion. She died at a New York hospital in part because of errors made by two residents powering through a 36-hour shift. In 1989, New York passed a law banning residents from working more than 80 hours a week and mandating shifts of 24 hours or less. ACGME adopted similar nationwide rules in 2003.
In 2008, the Institute of Medicine (IOM) produced a study funded by the U.S. Department of Health and Human Services that laid out the dangers of having doctors work long hours, including increases in needle sticks, motor vehicle accidents, and depression. (IOM is now the National Academy of Medicine.)
"The [National Academy of Medicine] study provides the clear evidence to prove what we have long believed is true — fatigue increases the chance for human error," Carolyn M. Clancy, MD, then-director of the U.S. Agency for Healthcare Research and Quality, said following the study's release. Among other things, it recommended that all residents work no longer than 16 hours without sleep.
In 2011, ACGME acknowledged the report's findings by limiting first-year residents to 16 hours. But many physicians have chafed under the new restriction — and under the ACGME limits in general. Surgeons and surgical residents have been especially critical. Harish Krishnamoorthi, MD, a third-year general surgery resident at Parkland, says resident restrictions occasionally get in the way of his training.
"Sometimes, we're working on a case and I actually have to leave the OR because I'm out of duty hours, and that's a little frustrating," he said.
Dr. Krishnamoorthi's view jibes with the findings of two recent studies. Last November, an analysis of a trial published in the Journal of the American College of Surgeons found 84 percent of junior general surgery residents prefer policies that let them work longer when needed. It also showed these policies don't hurt patient care. An earlier analysis in The New England Journal of Medicine showed flexible duty hours didn't worsen outcomes or hurt overall resident well-being. However, the analysis found more flexible policies did cut into residents' rest and leisure time.
Both sets of results came from a trial financed by the American Board of Surgery, the American College of Surgeons, and ACGME. The studies are part of ACGME's effort to review resident duty-hour requirements every five years. "Just as drivers learn to drive under supervision in real life on the road," said Thomas Nasca, MD, ACGME's chief executive officer, when the findings were published, "residents must prepare in real patient-care settings for the situations they will encounter after graduation."
Critics Weigh In
The debate over resident duty hours pits physicians against physicians, and some medical organizations have taken a stand — mostly to champion longer hours. (The Texas Medical Association has no policy on the ACGME rule change or on resident hours generally.) Other powerful voices have also tried to influence the debate. For instance, members of Congress prompted the 2008 National Academy of Medicine study because they were concerned about doctor fatigue.
Perhaps no group has been more critical of ACGME and medicine in general than Public Citizen, a consumer watchdog group with offices in Washington, DC, and Austin. Public Citizen has worked with the American Medical Student Association and physicians who are critical of the ACGME's role in relaxing limits on resident duty hours.
Public Citizen points out that other professionals whose work can endanger lives, such as airline pilots and truck drivers, must stick to more limited weekly schedules. They do so precisely to avoid fatigue. A study reported in the New England Journal of Medicine in 2004 found that interns made 35.9 percent more serious medical errors when they worked a "traditional" schedule that involved work shifts of 24 hours or longer. Other research backs up those findings.
"Study after study shows that sleep-deprived resident physicians are a danger to themselves, their patients, and the public," Michael Carome, MD, director of Public Citizen's Health Research Group, said in a press release. "It's disheartening to see the ACGME cave to pressure from organized medicine and let their misguided wishes trump public health."
Dr. Zammerilla says the exhaustion residents feel causes dangerous problems that go beyond work.
"I know that some of my co-residents have gotten into fender-benders on the way home from the hospital," she said. "Luckily, no one close to me has gotten into any serious accidents, but I can understand how that happens."
Other physicians argue the concerns about fatigue are important, but they have to be seen in a larger context. Daniel Dent, MD, the program director of the surgery residency program at The University of Texas Health Science Center at San Antonio (UTHSC-SA), says the need for training and continuity of care makes the debate about hours something bigger than the question, "Do you want a tired doctor?"
"Well, no, I don't want a tired doctor," Dr. Dent said. "If my wife develops a breast mass and has to see an oncologist or a primary care doctor tomorrow, I want it to be a well-rested, clean, hygienic physician who's taking care of her. But if my wife gets in a car wreck and has to go from the emergency room to the operating room to the ICU and back to the operating room with a different service and then back to the ICU, at the end of that 24- or 36-hour experience, I'd like her to look up and see some tired, disheveled, unshaven individual who sat with her through the entire ordeal."
Dr. MacClements says the debate over which schedule causes the most fatigue may also not be as clear-cut as it seems. Before 2003, a resident might work a tough 36-hour shift, he says.
"But when that person was done, they went home until the next day," Dr. MacClements said. "Right now, they might do 16 hours and be off for 10 hours, then back for 16 hours, then off 10 hours." As a result, he said, "the shorter rest period with increased frequency may not be as restful to the resident as we hoped." He says ACGME is doing ongoing research on issues like this.
Many physicians argue the ACGME rule change is needed to promote better mentorship for first-year interns. They point out that the first-year residents are on a 16-hour schedule while their supervisors are usually working different hours, so residents miss valuable learning time. Dr. Zammerilla said that concern seems overblown.
"I don't think that working 16 hours ever compromised my education or my ability to care for a patient," she said. "We're seeing them the next day, and we still play an active role in the longitudinal progression of their care."
Matters of Money
Despite the passions it provokes, the debate over resident hours does have areas of common ground. For instance, most people on both sides agree that a lack of funding for health care in general and the nationwide shortage of doctors are big parts of the problem.
The 2008 National Academy of Medicine report stated, "Financial costs and an insufficient health care work force are the biggest barriers to further revising resident hours." At the time, it estimated that the additional costs of shifting some work from current residents to other health care personnel or additional residents could be as high as $1.7 billion per year.
Robert Nolan Jr., MD, associate dean for graduate medical education at UTHSC-SA, says medical institutions have to be realistic about budgets and about how much change is possible. He says many medical students and residents point to countries in Europe as places that provide more reasonable resident hours. He agrees those systems provide high-quality medical training but says mimicking them would require difficult trade-offs. For instance, residencies in Europe typically last much longer, and senior practicing physicians are paid much less.
"We're having trouble even nibbling at the edges of political change in our medical care system," he said. "The notion of radical change is simply off the table."
Even if ACGME decided to keep the shorter hours for first-year residents, the issue of resident fatigue will not go away soon. It poses an ongoing problem for hospitals because the ability to handle long shifts varies from person to person. Lois Bready, MD, vice dean for graduate medical education and the designated institutional official at UTHSC-SA, says residents and supervisors often struggle to tell when someone is overextended and needs to go home.
"Underlying that is, how can we determine fitness for duty?" Dr. Bready said. "How can we tell who the tired-but-still-highly-functional doc is? Without being able to easily test for fitness for duty, it makes everything else dependent on rules or standards." She added, "We would nominate for a Nobel Prize someone who comes up with a functional, valid means of assessing fitness for duty."
The debate over resident hours stirs so much interest because it affects doctors at the workplace. But the medical community is hardly polarized. Michael Metzner, MD, a first-year general surgery resident at UTHSC-SA, laughs about how torn he is on the subject. On one hand, he says he understands the need for total commitment — including working long hours — to become a skilled doctor. "If you love what you do, you really don't think about the hours," he said.
On the other hand, he points out that burnout is a common problem among doctors, and a recent study in the Journal of the American Medical Association found that one in four medical students is depressed. "Of course the patient comes first," he said. "But at what cost to the individual? Because if we're not healthy and we're not leading healthy lives, how are we supposed to be treating other people?"
Sean Price can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
Resources for Surviving Residency
TMA provides a variety of tools and resources that help residents with stress and guide them into their first practice. These include:
- Advocacy on resident work hours, physician-in-training permits, and other issues;
- Loans to resident physicians within Texas;
- The Texas Jurisprudence Manual and Study Guide, which helps residents prep for the Texas Medical Board test;
- A members-only resident video library, which covers business-of-medicine topics; and
- The TMA Knowledge Center, which quickly answers questions about health care, health law, practice management, medical economics, and public health.