To Sleep, Perchance to Dream: New Guidelines for Residents

Neil Canavan, MSc

March 25, 2011

March 25, 2011 — The new policy regarding duty hours from the Accreditation Council for Graduate Medical Education (ACGME) will go into effect July 1. Although these long-considered changes are most welcome, deciding what to do if your institution breaks the rules may require more than just sleeping on it, according to representatives from the Committee of Interns and Residents (CIR), a union of interns and residents with more than 13,000 members, here at the American Medical Student Association (AMSA) 61st Annual Convention.

"Work hours is a charged issue with a lot of people on both sides," said Sonia Lazreg, health justice fellow, AMSA/CIR. Knowing the details of the policy and anticipating push-back from workplace supervisors will help to ensure the integrity of these much-needed changes, she added.

The concerns that CIR has about policy violations are fueled by precedent. After years of advocacy by AMSA, CIR, and others, the ACGME instituted an 80-hour work week in 2003, yet by 2006, when an ACGME survey indicated near universal compliance with those measures, an independent study from the Harvard Work Hours Health and Safety Group showed that 83% of interns were in violation of the new standards. "The problem in evidence here is that if rules are broken, your program can be put on probation, or potentially even shut down, so it's really hard for residents to step up and say if there are violations because there is too much at stake," Ms. Lazreg said.

For some, the seriousness of the issue is relative. If, at the end of the potentially 30-hour day, the result is a stellar medical education and glowing recommendations from your attending, why not bend the rules if need be? Ms. Lazreg responded to this by stating: "We know that not having recovery sleep — a chance to bounce back from nights on call — affects how memories are formed and how well you learn." If education is your main concern, marathon shifts are not the answer.

According to data collected in 2007 by the Institutes of Medicine, an independent, nonprofit organization of physicians and scientists, after 24 hours of continual work, there are 37% more medical errors, and residents are twice as likely to have attentional failure — a condition in which for a few, perhaps critical, moments, a person forgets what they are doing. As suggested by a study in the New England Journal of Medicine, this can have a profound effect on the resident as well as the patient. One in 5 residents believes they committed a fatigue-related error in the first year of residency, and 1 in 20 thinks that error led to a patient death.

Even after the 2003 ACGME guidelines were implemented, the potential to do fatigue-related harm was not fully mitigated. Changes taking effect in July will include increased supervision, continuous-hour shifts of 16 or fewer hours (for interns), work weeks of 80 hours (including home calls), and a decrease in mandated time between shifts from 10 to 8 hours.

"Obviously, there are still problems here," said Ms. Lazreg. "For example, being on call can be averaged over 3 days, so that can work out to being every other day," and despite the ACGME's good intentions, there is no suggested mechanism for how the rules should be enforced.

There is also the expected push-back; attendings suggest that a resident's education, or an institution's operations, might be compromised. Anticipating this, the CIR has put together the Work Smart Toolkit, a comprehensive document that includes tips and resources for responding to workplace resistance to ACGME policy, and examples from residency programs illustrating how this new paradigm can be successfully implemented.

American Medical Student Association (AMSA) 61st Annual Convention. Presented March 12, 2011.

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