Editorials

The working and learning environment for physicians in training in the US

Limits on resident work hours, with financial and staff support, are needed

Editorial BMJ USA p 75

This article originally appeared in BMJ USA

As in Europe, interns and residents have played a critical role in the US health care system for decades. Generations of young physicians fresh from medical school have willingly exchanged up to 130 hours each week fulfilling the service and educational requirements of their training programs for the experience of patient care and the promise of a career in medicine. As we enter a new century however, this "rite of passage" endured by thousands of physicians has fallen under greater scrutiny by the American public.

In 1984, a young woman (Libby Zion) admitted to a New York hospital died due to an adverse drug reaction allegedly missed by a fatigued and overworked resident. Although a subsequent grand jury investigation found no fault with the physician or hospital, the public outcry surrounding the case resulted in strict regulations in the state of New York that mandated limits on resident work hours.

In the decade following the Libby Zion case, limiting resident work hours remained the responsibility of the Accreditation Council for Graduate Medical Education (ACGME), a private professional association charged with accrediting residency and fellowship programs. Each specialty, through its own individual Residency Review Committee (RRC) of the ACGME, sets work limits for training programs. These voluntary limitations however, are quite varied by specialty. For example, the guidelines for general surgery state that "continuity of care must take precedencewithout regard to the time of day, number of hours already worked, or on-call schedules" and "it is desirable that residents have at least 1 day out of 7 free of patient care responsibilities and be on call no more often than every third night." Despite these somewhat open-ended regulations, more than one-third of general surgery programs surveyed in 1999 and 2000 failed to meet the above requirements.¹ Other specialties regularly fail to comply with the work hour limitations set by their own RRCs in up to 20% of training programs.

In April 2001, frustration with the ACGME's lack of progress in curtailing excessive hours led several organizations representing medical students, residents, and the public to petition the Occupational Safety and Health Administration (OSHA) to set a federal standard for resident work hour limits. Citing scientific studies showing that fatigued residents are at higher risk of automobile crashes, suffering depression, and delivering premature infants, these groups reasoned that residents should have the work limitations already imposed in the trucking and airline industry as a matter of employee safety. Ironically, the petition cited provisions of the European Working Time Directive, which will eventually limit European physicians in training to a 48-hour work week (BMJ USA p 75),² just to argue for an 80-hour weekly cap for American residents.

Although a final governmental ruling on the OSHA petition is not due until this spring, Representative John Conyers, Jr (D-MI), wasted no time in introducing the "The Patient and Physician Safety and Protection Act" in Congress in October 2001. The first proposed national regulation of resident working hours mirrors many aspects of the New York State regulations, including an 80-hour-per-week limit, a limit of 24 consecutive hours on call, and one in seven days free of patient care responsibilities.³ Supporters of the legislation hope that the government can accomplish what private groups such as the ACGME have been unable to do, although how the US government would enforce the new standards is unclear. The effectiveness of such laws is questionable, especially when in New York, more than 10 years after the establishment of the Libby Zion laws, residents routinely work more than 110 hours per week despite annual fines in excess of $20 000 levied on hospitals that often consider such fines "the cost of doing business."⁴

As in other industries, there is a growing body of evidence that fatigue may play a role in medical errors.⁵ A recent European study demonstrated that surgical trainees committed more errors while performing simulated laparoscopic procedures following a night on call.⁶ Studies are currently underway in several US medical centers evaluating the impact of fatigue on medical errors in order to develop relevant countermeasures. Regrettably, as more evidence links fatigue and medical errors, the problem of excessive resident working hours may not be resolved by the medical community, private accrediting agencies, or the government, but by the US court system.⁷

In the United States, many hospitals are operating with unprecedented deficits. Urban teaching hospitals with severe nursing and ancillary staff shortages depend on residents to perform numerous tasks that do not advance their educationin order to "cover the house." The stress placed on American graduate medical education is merely a symptom of a health care system continually being asked to do more with less. Perhaps we can learn from our European colleagues on how to best reduce the burden on our physicians in training. However, without adequate financial and staff support, attempts to limit resident hours will prove futile.

American Medical Association,Chicago, Illinois, USA Peter_Watson{at}ama-assn.org

Pickersgill (BMJ USA p 75) http://bmj.com/cgi/content/full/323/7324/1266