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Scott Harris
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Elissa Fuchs
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ACGME Duty Hours Standard Sparks Regulatory Debate

By Suria Santana

The Accreditation Council for Graduate Medical Education's (ACGME) June recommendation for an 80-hour work week for medical residents has once again put the contentious issue of resident-physician work hours into the national spotlight. Front-page news around the country, the standard has sparked debate on whether the issue is better handled through academic medicine's self-regulatory mechanisms or through legislation at the state or federal level.

The ACGME released the new standards June 13, one day after Sen. Jon Corzine (D-N.J.) introduced legislation limiting resident-physician work hours to 80 hours per week and 24-hour shifts. Corzine's bill calls for public disclosure of hospitals that violate work-hour limits and is a companion to Rep. John Conyers' (D-Mich.) H.R. 3236, introduced in November 2001.

The new ACGME regulations intend to lighten residents' burdens by limiting their weekly work schedule to no more than 80 hours per week, except in cases where an institution can show an "educational rationale" for increasing hours by up to 10 percent. The new standards also set a minimum rest period of 10 hours between duty periods, and require teaching hospitals to give residents at least one full day off from patient care duties every week. The standards further restrict moonlighting to ensure control over the total number of hours residents work, and they limit the number of consecutive nights residents may work to three.

The AAMC has been on record for two decades advocating strict duty-hour requirements for physicians-in-training. As a member organization of the ACGME, the AAMC has advocated the need for an 80-hour standard throughout the council's recent consideration of the issue.

At the same time, the AAMC also strongly opposes a legislative remedy to the work-hours issue. "The unquestionable excellence of graduate medical education in the United States is in no small part traceable to the effectiveness of the medical profession's self-regulatory mechanisms for assuring compliance with the high standards established by experienced educators and practitioners," wrote AAMC President Jordan J. Cohen, M.D., in a January letter to Rep. Conyers.

In a public exchange with Conyers on the national radio program "The Diane Rehm Show" June 17, Dr. Cohen said to Conyers: "Let me be the first to ask you to withdraw your bill...Now that the ACGME has stepped forward, we should allow that system to effect the kinds of changes we are all eager to see happen."

The ACGME, for its part, believes the problem with having state or federal statutes dictating limits on resident duty hours is that such laws are slow to adapt to changes and developments in the clinical and educational environments.

"Congressional statutes, once passed, are very rigid and require an act of Congress to modify," says David Leach, M.D., the ACGME's executive director. "The ACGME is the appropriate body to enforce reform. The 80-hour limit on resident duty hours might not be the right [limit], and our organization is in closer contact with emerging clinical reality and could adapt more quickly than Congress."

The ACGME has made it a point to take a comprehensive approach to graduate medical education, going beyond the duty hours issue to include an emphasis on supervision and accountability, and be especially alert for signs of resident sleep loss and fatigue.

"It's about time that the educational model realize that the 'Lone Ranger' is no longer the appropriate metaphor," Dr. Leach said. "Instead, it is [more like] the U.S. Navy SEALs; a team approach to health care."

Students weigh in

Eric Hodgson, M.D., president of the American Medical Students Association (AMSA), argues that limits on resident hours can be enforced only through federal regulation as well as public disclosure of violating hospitals.

"It's encouraging that the ACGME is addressing the resident work-hour issue, but the guidelines...have very limited enforcement mechanisms," Dr. Hodgson says.

"Under the guidelines, I could be a resident at a hospital that has received multiple sanctions for my work hours, but there's no guarantee that I, or the public, would know that there are problems," he says. The guidelines don't include public disclosure, which makes them virtually ineffective and ultimately compromises patient safety." Dr. Hodgson adds that the participation of investigative entities outside the medical community can further ensure that resident duty-hours limits are followed by institutions. He cited New York state's regulations as an example.

New York is the only state in the country that limits resident work hours. In 2000, Gov. George Pataki (R) set aside state funding to support inspections on resident work hours. This surveillance initiative is conducted by the Island Peer Review Organization (IPRO) through a contract with the state's Department of Health. In June, the department cited 54 teaching hospitals for resident duty-hour violations.