Tired Residents Still at Risk: The Limitations of Self-Regulation

Editorial from the 2003 Legislative Affairs Director

Enter a teaching hospital anywhere in the country this week and you will witness history in the making. After nearly 20 years of inaction, the medical community has adopted new regulations governing the working conditions of physicians-in-training. For decades, medical residents have been among the lowest-paid, hardest-working laborers in the medical profession. Standard hospital practice prior to July 1 meant forcing residents to work as many as 120 hours a week in shifts as long as 36 hours. For many physicians, this "rite of passage" transformed naive medical students into skilled, capable physicians. Over the past three years as a medical student, I have worked alongside these incredible individuals, and have seen the destructive effects that fatigue has on the ability for residents to provide expert, compassionate care. As a future physician, it concerns me that these new guidelines, while historic in their significance for medical education, have severe and compromising limitations.

In recent years, evidence has shown the risks associated with this type of medical training. Studies found that residents had higher pregnancy complications, were more likely to get in fatal traffic accidents, and had higher rates of depression. The Institute of Medicine estimated almost 100,000 annual deaths due to medical errors. And one study equated fatigued residents' ability to perform skilled tasks to be at about the same level as people who were legally drunk. The implication for patient safety is music to the ears of any malpractice lawyer. The medical community chose to disregard this evidence, and ignored pleas from residents and patient advocacy groups to enforce the work hour guidelines it had nominally had for over 20 years. Only in New York - and then only through the highly publicized negligent death of Libby Zion - were work hour regulations enacted.

Through the advocacy efforts of the American Medical Student Association and Public Citizen, the issue of resident work hour reform took national stage when federal legislation proposed that resident work hours should be regulated as a condition of Medicare funding. The Accreditation Council for Graduate Medical Education, which is the licensing body for resident training programs, took action only when federal oversight threatened to interfere with the tradition-sensitive system of medical education.

The new regulations limiting resident physicians to 30 hour shifts and 80 hours a week (averaged over four weeks) have been hailed as the greatest change in medical education in many decades. However, these regulations are unlikely to drastically improve patient and physician safety. The ACGME, in avoiding federal oversight, has created regulations with built-in loopholes to allow hospitals to continue working residents for long hours with little sleep or time off. Through individual exemptions, averaging of hours, and poorly-defined "non-patient care activities," many residents will continue to work as much as 100 hours in any given week. Patients will continue to be put in the care of fatigued, overworked resident doctors.

Patients treated in hospitals that abuse young physicians will have little recourse. The regulations provide no public disclosure of programs found to be in violation. For residents, there are no whistleblower protections to provide young doctors with the ability to report their programs if they are forced to work intolerable hours. Additionally, the mechanism for enforcement results in a loss of program accreditation - a sanction that threatens residents' future careers and patients' access to care. Under these regulations, residents who report their programs' violations risk losing the ability to become licensed physicians and will likely incur the scorn of their supervising physicians - the very individuals they count on to provide career advancing recommendations.

Federal legislation is the only way to guarantee that patients and physicians are safe from the effects of fatigue and abuse. The medical community, in providing loopholes to protect hospitals and programs rather than residents and patients, has proven that it cannot regulate itself. Legislation pending in Congress would provide adequate enforcement and oversight of residency programs that train our nation's young physicians. Senator Jon Corzine (D-NJ) and Representative John Conyers (D-MI) have introduced the Patient and Physician Safety and Protection Act of 2003 that would close these loopholes, provide residents with the enforcement and protection they deserve, and ensure that fatigued residents do not put patients' safety at unnecessary risk.