To the Editor: Excessive work hours in residency training programs have long been a source of concern and the topic of debate among members of the medical community. Physicians often tell "war stories" to one another about the long hours, difficult conditions, and heavy clinical load they experienced during their residencies. However, the general public became more aware of these issues in 1984 after Libby Zion, an 18-year-old woman who was cared for primarily by residents, died unexpectedly at a teaching hospital (1). At that time, the New York State Ad Hoc Advisory Committee on Emergency Services reviewed the grand jury report and recommended guidelines for eight specialties, including psychiatry, requiring experienced supervisors for the residents on site at all times and limiting the resident's duty and on-call hours. Emergency rooms that had more than 15,000 visits per year were to limit the residents' work to 12 or fewer hours per day. "Moonlighting" was to be monitored and nonworking time specified.
In 1998, 14 years after the Zion case was deliberated, a survey (1) by the New York State Department of Health found that most of the guidelines issued by the Advisory Committee as a result of that case were being followed. Overall, resident supervision was in place, outside work of residents was satisfactorily monitored, and emergency rooms complied with specified work requirements. The problem area for many programs in adhering to the issued guidelines was resident work-hour compliance, which was particularly noted in surgical residency programs. Twenty percent of all residents and 60% of surgical residents worked more than 95 hours per week.
Studies (2—4) indicate that expected resident duty hours differ between medical specialties, and resident workload varies greatly. Most residents in the United States work two or three 36-hour shifts per week, plus their regular 12- to 14-hour day shifts (6). At first glance, these numbers sound daunting to the average reader. Ninety-five hour weeks are more than double the standard work week required in most fields. However, the question of how resident duty hours are defined becomes very important when trying to evaluate current program conditions and enforce existing or new regulations. In the past, efforts have been made to gather data to determine the effects of current residency requirements; however, differences in program definitions of a "duty hour" make it difficult to use the reported work hours for comparative evaluation of resident fatigue and function.
To determine duty hour definitions in psychiatry programs in Texas, a survey was sent to nonmilitary training programs. This written survey, sent to the training directors by the author, yielded varying results. Seven of nine programs responded. All respondents indicated that on-duty time was calculated as travel time between assigned work sites, time spent on an assigned rotation, and time in class or required meetings. Two-thirds of the programs did not consider on-call time at home as duty hours. Most programs did not consider travel time to and from a single assigned rotation as duty time, but one program stated that essentially anything the residents did that was work related was counted in their estimation of duty hours. Clearly, the reporting of duty hours can be misleading unless a standard definition for what constitutes a duty hour is used.
There are differing opinions within the medical community as to the possible outcomes of a more strictly regulated residency work-hour compliance initiative. Patient safety is always a primary concern, but many are concerned about the welfare of residents working within current program conditions. Systematic studies of problems secondary to resident fatigue, specifically medical errors, motor vehicle accidents, lapses of attention, cognitive slowing, and mood changes are now in process. Concern also exists over legal liability for training institutions when there are lapses in medical care. Yet, some faculty members have predicted that limiting the work hours of residents would result in "ill-equipped" physicians. Others have voiced their concern about continuity of care, insufficient exposure to pathological disorders, and poorly attended classes and other teaching sessions.
A 1999 study (8) by the Accreditation Council for Graduate Medical Education (ACGME), the accrediting body for resident medical education programs in the United States, indicated that almost 20% of institutions reviewed had not met current duty-hour requirements. In protest, a petition was filed with the Occupational Safety and Health Administration (OSHA), the federal agency responsible for enforcing safe and healthy working conditions, on April 20, 2001 by several key organizations, including Public Citizen, the American Medical Association, and the Committee of Interns and Residents. The petition noted that no residency program had been penalized because of work-hour compliance deficiencies and demanded that OSHA enforce the existing standard by regulating duty hours for resident physicians.
In response to concerns about sleep deprivation effects on patient and resident safety, ACGME appointed a Work Group on Resident Duty Hours and the Learning Environment. On June 11, 2002, ACGME sent a draft of standards for resident duty hours out for review.
The ACGME report (9) recommended standards in the following areas: definition of duty hours, institutional oversight, quality education, and safe, effective patient care. Recommendations included a cap of 80 duty hours each week, which may be increased by 10% with appropriate justification; a weekly 24-hour duty-free period; and an in-house limit of no more than every third day on-call, averaged over a 4-week period. It was also recommended that after 24 hours on duty, there may be 6 additional hours used for classroom time and the transfer of patient care, and there must be at least 10 hours of rest time after call. The physical and emotional well-being of residents is to be monitored as is the amount of patient care or support service time with limited or little educational value. Implementation of these recommendations occurred in July 2003.
The issue of residency work-hour regulation is complex and ongoing. The ACGME proposed standards defining resident duty hours are a large step forward in the ability to obtain comparable data so that an accurate evaluation of current programs can be made and a reasonable quantity of resident work can be determined.