Institute of Medicine Studies Resident Work Hours & Patient Safety

The Institute of Medicine has trained its sights on resident work hours. Best known for its seminal 1999 report “To Err is Human,” the IOM responded to a request from Congress and the Agency for Healthcare Research and Quality to convene a Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety.

“CIR was honored to be among the Committee’s first presenters at a public hearing on December 3, 2007 in Washington, DC,” says CIR President Dr. Luella Toni Lewis. “As a union, we have been active for more than thirty years in highlighting the critical connection between our long hours, patient safety and resident education and well-being.

“In 1975, CIR forced an end to across-specialty every other night call in New York City’s public hospitals. In 1987-89 we pressed for New York State hours regulations in the wake of the Libby Zion tragedy. And CIR joined with the American Medical Student Association and Public Citizen in 2000-02 to press for federal work hours legislation and OSHA protection. This activism culminated in the ACGME’s decision to establish across specialty ‘duty hours’ in July 2003.”

Dr. Lewis said that CIR’s message to the IOM was simple: look at the overwhelming evidence before you that links acute and chronic sleep deprivation with significant attentional and performance deficits, increased medical errors and danger to residents who are exposed to an increased risk of needlesticks and post-call car crashes. AMSA, Public Citizen and Harvard sleep scientists Drs. Charles Czeisler and Christopher Landrigan also presented testimony calling for the IOM committee to act on the evidence and recommend that the hours of resident physicians be reduced to safer levels.

“It’s time for the ACGME to recognize,” said Dr. Lewis, “that its current rules, which allow for shifts of 24+6 hours in the hospital without sleep, are too long and unenforceable because they depend solely on resident self-reporting – not generally something residents are willing to risk their careers to do.”

Excerpts from Remarks by IOM Study Sponsor Carolyn Clancy, MD Director, Agency for Healthcare Research and Quality “As you know, some of our colleagues continue to believe that there is no correlation between the extended work hours of graduate medical trainees and quality of care. They say the long hours are part of the training and reduction would put these trainees at risk of missing valuable learning opportunities. You and I know better.... “I think the bottom line is that there must be change. The era of graduate medical trainees being exposed to extended hours for no good reason is about to come to a close. The reasons for keeping this going are not rooted in science. They are based on opinion and tradition – perceived rather than actual barriers to change... “With this committee we have a chance to go beyond providing answers.We can provide solutions.We can send Congress recommendations that can have an impact in the quality of care across the nation. Thank you very much for being a part of this panel. I am already looking forward to reading your report next year.”  Full Remarks of Carolyn M. Clancy, MD

Dr. Nailah Thompson, CIR’s Executive Vice- President, attended the IOM’s second public meeting held in Irvine, CA on March 3, 2008. During the public comment period, she urged the IOM to “take under consideration the dangers that the nation’s 100,000+ resident physicians pose to themselves and the general public when they get behind the wheel of a car in an impaired state due to acute and/or chronic sleep deprivation.”

Dr. Thompson stressed the growing public awareness of the dangers of ‘driving while drowsy’ and the number of states with proposed legislation to criminalize DWD. This type of legislation poses particular risks for residents with documented work schedules that would be banned in other industries entrusted with the public’s safety, such as trucking, the airlines and nuclear power plants.

In its verbal and written presentations at both IOM public hearings, CIR made three key recommendations to the Committee:

• Act on the scientific evidence and recommend shifts for resident physicians that are no greater than 16 consecutive hours;
• Recognize that change will not occur unless all teaching hospitals are required by law to adhere to the same safe hour limits;
• Insist on rigorous enforcement of work hour limits by an external agency that has no economic self interest in perpetuating the status quo.

 

Proponents of Status Quo Weigh In


The IOM committee has also heard from many hospital CEOs, residency program chairs and program directors who adamantly oppose any further reduction in resident work hours beyond what the ACGME currently sanctions. They maintain that an increase in patient hand-offs and deploying of the current number of residents more thinly would increase medical errors. Others pointed to the cost of hiring additional healthcare providers as prohibitive. Two presenters – from St. Luke’s Roosevelt Internal Medicine in New York City and Harbor-UCLA General Surgery in Los Angeles – reported on how they had reduced residents’ work hours after the ACGME’s new limits in 2003 through innovative scheduling and some additional financial resources – all with positive results. But their presentations were overwhelmed by those arguing for the status quo.

“We recognize that this is a complicated situation – this juggling of patient safety, resident education, economics and culture,” testified Dr. Lewis. “A rigid reduction in hours worked without analyzing how the work is organized is doomed to failure. That’s why CIR stresses the need to reengineer how the resident workday is organized....We applaud medical educators who recognize that reducing resident work hours is actually an opportunity to re-think the entire training paradigm. It can be done and it must be done.”

The IOM committee is scheduled to release its report at the end of 2008.