For the past five years first-year residents have been limited to working 16-hour maximum shifts. Before 2011, they were allowed to work 28-hour maximum shifts. But that was changed after a 2009 Institute of Medicine (IOM) report found that residents working 24-hour shifts were more likely to injure themselves and their patients, and had an increased risk of having a car accident due to driving while sleep deprived. Now, the Accreditation Council for Graduate Medical Education (ACGME) wants to change it again, increasing the maximum limit back to 28 hours. So why the sudden change of heart?
There’s been pressure from physician groups who believe the shorter shifts have undermined patient care by increasing the number of patient handoffs between doctors. Increasing the number of times interns pass their patients’ care onto someone else to continue treatment, can introduce more opportunities for errors to creep in, says the ACGME in an NPR article.
The proposed, extended work-hour limits would once again put first-year doctors in alignment with second- and third-year supervising doctors who care for the same patients. ACGME CEO, Dr. Thomas Nasca, told Medscape Medical News, “the lack of synchronization is very disruptive.” And said the solution was to put “everyone on the same clock.”
In a Washington Post article, Dr. Nasca added that the goal is to “improve the coordination of clinical care by the interns and residents in the teaching environment.”
Doesn’t change everything
While the proposal increases shift lengths, it doesn’t change the rules meant to protect residents from overwork. The maximum hours a resident can work per week would remain at 80 averaged over four weeks. And residents would still be required to have at least one day off per week from clinical experience and education, and would still be limited to one overnight shift every three days.
New requirements in the proposal require supervisors to monitor the mental health and well-being of their interns due to burnout, depression and suicide being on the rise in the medical profession, said Dr. Nasca in the Washington Post article. Program directors would need to educate teachers and students on how to detect and treat burnout, depression, substance abuse and suicidal thoughts in interns.
One final note on the proposed rule is teaching hospitals wouldn’t have to use the 28-hour shifts for interns, noted Dr. Nasca in a Forbes article. If they want to stick with the 16-hour shift configuration they’re allowed.
As you can imagine, the ACGME’s proposal is quite controversial.
In a news release, consumer watchdog group Public Citizen says the proposal is a “dangerous step backward and, if implemented, would expose residents, their patients and the general public to the risk of serious injury and death.”
Dr. Michael Carome, director of Public Citizen’s Health Research Group, said “Study after study shows that sleep-deprived resident physicians are a danger to themselves, their patients and the public. It’s disheartening to see the ACGME cave to pressure from organized medicine and let their misguided wishes trump public health.”
The group also noted in the release that what the ACGME is proposing goes against what the American people want. Public Citizen commissioned a public opinion pole and found that “four out of five Americans oppose any resident physician working more than 16 hours in a row without sleep.”
The watchdog group is also mobilizing a number of medical and patient groups (American Medical Student Association, Service Employees International Union’s Committee on Interns and Residents, National Physicians Alliance, Consumer Union) to continue putting pressure on the ACGME to uphold the 16-hour limit and extend it to all residents.
New study offers supporting evidence
So why are they proposing the rule if studies show it can harm patients?
According to ACGME, recent research found that the relaxed rule wouldn’t increase risks for patients.
A study published in the New England Journal of Medicine showed that patients in programs without shift limits didn’t have a greater risk of post-surgical complications or death. And residents working these longer shifts weren’t more dissatisfied with their overall well-being.
The ACGME is taking public comments on the proposal until Dec. 19. If approved, the new requirements will go into effect in July when the new class of medical school graduates start their residencies at teaching hospitals.