The 80 hour work week

Medical residents limited to 80-hour week. I ranted often about this subject last summer. This article and decision are not a surprise. Our program has already made the necessary adjustments to call schedules so that we can accomodate the necessary changes.

Doctors-in-training in the United States — who work marathon shifts and 120-hour weeks that critics say lead to medical mistakes — cannot work more than an average of 80 hours a week, a body that accredits medical residents said Tuesday.

Under new rules approved by the nonprofit Accreditation Council for Graduate Medical Education, medical residents must also get one day off out of seven and a 10-hour rest between being on call and working a shift. The rules, which schools must follow to be certified, take effect July 1.

The vote by the council’s board of directors means the standards “go from being a should, to a must” in order to pass muster with the accrediting body, said Julie Jacob, a spokeswoman for the group.

Working with internal medicine residents, we have had the 4 days off each month rule for the past 5 years. While it sometimes seems like an inconvenience, it is a very good rule. Since initiating this rule, I see much less housestaff depression and burnout. We often arrange for housestaff to get the entire weekend off (on the golden weekend – the weekend when the team is on call Thursday night and Monday night). Having a long weekend allows for mini-vacations which greatly improve ones mood.

Medical residents and the consumer group Public Citizen prefer federal standards, saying a private group lacks teeth to enforce the rules. But the government rejected a petition to a federal agency on that front last year.

The Committee on Interns and Residents, a union that represents 12,000 residents in the United States, said the move “is going in the right direction, but the weakness is enforceability,” according to executive director Mark Levy.

Another flaw are loopholes that allow residents to extend for example, the 24-hour shift limit by six additional hours, Levy said.

I beg to differ with Mark Levy. Enforceability will work, because the ACGME has the ultimate threat – discontinuing the residency program. Some programs might try to cheat – but they will be caught. They will also quickly lose the yearly battle for interns. Medical students find out who complies and who does not. They will not choose cheating programs.

I strongly disagree with the 24 + 6 rule. This is the single part of the new guidelines causing the great compliance problem. We have developed a unique solution that I believe will work.

The problem here is continuity of care. We all worry about the “pass off”. What happens to patient care when you change physician responsibility? The “pass off” represents the danger in these rules. We have spent much effort developing a plan to insure that the responsibility stays within a team structure. Our solution looks good on paper, but we will know the flaws when we start this process soon. We are planning to do several trials of our new system over the next few months. And then we “go live” in July, with new interns. I plan to be ward attending in July. I will try to remember to rant as things work or do not work.

A nice feature of our new system is a decrease in overnight call. Our interns will generally stay overnight in the hospital every 8th night rather than every 4th night. A downside is the necessity of a night float system. We have avoided the night float (making us a minority program) for many years. I hope we can make that system work well.

Most important I hope that patient care and education do not suffer. These are the two standards which one should use to judge these changes. I believe that the ACGME has acted too aggressively, without carefully studying the impact of these new rules. But they did not listen to widespread criticism. They acted unilaterally, and we will play ball by their rules.