Earlier this month, the Accreditation Council for Graduate Medical Education (ACGME) – the organization that monitors the training of more than 100,000 residents in 114 specialties – announced new rules that will limit the number of hours worked by medical residents. The new guidelines are to take effect in July 2003 and will limit the workweek to 80 hours, require at least 10 hours of rest between shifts, restrict duty to no more than 24 hours at a time and restrict work outside the hospital. 
In light of the crescendo of national opinion about the meaning of the new ACGME regulations, Robert S. Wigton, M.D., associate dean of graduate education for the UNMC College of Medicine, offered an overview of the issues that led to the historic change in regulations and reflected on how these changes may affect future medical residents.
“First of all, it’s important to understand that this is actually a part of an incremental change,” Dr. Wigton said. “These changes have been going on for the last 20 years, but have picked up in intensity in the last decade.
“The concept of the intern was started in the early 1900s because hospitals needed to hire doctors to stay in overnight. That’s why interns were originally called house doctors or house officers. Over time, internships turned into specialty education programs called residencies. In the very beginning, residents couldn’t marry; they lived at the hospital and had this incredibly demanding professional life. But since the 1950s, life has gotten closer to normal for most resident specialties; the hours have gotten better and so on.
“That’s why I see the new ACGME changes as being just the next stage of on-going changes in American medical education. Medical training is always evolving to meet new challenges.”
There are probably as many as 1,500 institutions in the United States that support residency programs. Each of these institutions may have 20 or more different residency programs, and each program has its own residency review committee (RRC). Up to this point, the ACGME allowed each specialty’s RRC to dictate its residents’ work schedule. Dermatologists, for example, determined the hours per week necessary to fulfill a dermatology residency. Under the new guidelines, all of these independent RRCs must follow the same rules.
According to Dr. Wigton, almost all residency programs, except some of the surgical specialties, have had some form of the 80-hour workweek; almost all programs offer one day off per week; and they’ve all had a rule of every third night on call. The state of New York revised its residency work hours 15 years ago to just such a set of standards, and now the ACGME’s model will be similar to New York’s.
UNMC has 27 different residency programs, and the new guidelines may challenge some programs much more than others, especially the requirement that residents can’t be on duty more than 24 hours straight and, once off, they can’t go back on duty for at least 10 hours.
“I think a lot of people outside our profession don’t understand how coverage is done at night,” Dr. Wigton said. “If you’re on call, you come in and take care of patients during the night. Then, in the morning, you make the rounds of your patients and later do your business of the day. The new rules say you can’t see any new patients after you’ve been on call all night.
“Eighty hours may seem like a lot of hours until you factor in being on call for three nights. Being on call easily adds 14 or 16 hours to the workweek each time and many residents are on call two or three times a week. People keep wondering why so many residents rack up 80-hour-weeks or more. It’s because of all the on-call shifts.
“Now factor in that a resident in surgery or OB/GYN who may be following someone all night and don’t wish to leave that patient’s care to another doctor, missing important events in their care after hours of monitoring. So, residents in surgery or OB/GYN, for example, can easily run up 100 or more hours in a week.”
Breaking the continuity of patient coverage and, by extension, residents’ educational opportunities, is considered a potential major downside to the new regulations. Some residents feel that the more humane their schedule, the more they may stand to lose on education from every evolving patient issue.
Yet, residents who are there all the time run the risk of fatigue and possibly making a error, as well potential consequences to maintaining a personal life. Medical schools seek a balance between interpretive training and the length of training. Allowing residents a more normal life may mean that some residents programs will take longer to complete because the residents can no longer put in the extensive daily work schedule that could mean finishing a residency more quickly.
In addition, work hour issues are now taken serious enough that a residency program may find itself on probation if it doesn’t enforce ACGME guidelines. The main point of the new regulations is not to restrict education. If a program really needs its residents to work more than 80 hours a week, the program can petition the ACGME for extended hours based upon specific educational needs.
“The ACGME has been pushed heavily for the last two years by a lot of organizations,” Dr. Wigton said. “Congressional committees have gotten in on the issue, along with residents’ organizations and public organizations. When the issue of patient safety was tied to medical error and error tied to possible resident fatigue, a lot of constituents converged on the topic.
“There are more resources available for hospitals today to pay for a lot of services that residents have traditionally filled – accounting for a lot of hours worked that weren’t necessarily educational – such as blood draws and patient transportation. Also, there is a new mindset among residents today. When I was a resident, I didn’t have a family and it was nothing to me to stay over on a Saturday. And practice is changing now. People are more used to call coverage and trading off.
“These new regulations are really just about changing with the times. Medicine is getting more outpatient and less inpatient. The old system of learning mostly in the hospital is slowly giving way to learning more in the clinic situation. There is a growth in technology of simulated medical models. Future residents may not be able to get every kind of learning experience they need at the clinic or the hospital in a given amount of time. So, all in all, we’re just recognizing that we can make residents lives better, yet provide the quality education their specialty demands. And, certainly, people just learn more efficiently if they are well rested.”