Resident work-hour limits still a struggle one year into restrictions

First-year family medicine resident Julie Silverhart, MD, says that, for the most part, her hours at Greater Lawrence Family Health Center in Lawrence, Mass., fall within the standards set by the Accreditation Council for Graduate Medical Education. But she also acknowledges that during her first month in internal medicine, she worked more than the average of 80 hours per week allowed under the guidelines.

Dr. Silverhart's experience is fairly typical as residents and programs adjust to the work-hour limits that went into effect in July 2003. Residents say programs are in compliance for the most part, but sometimes they are not.

ACGME enforcement of the regulations has garnered mixed reviews. The Committee of Interns and Residents, a staunch critic of the ACGME, is skeptical of programs and resident claims that they are mostly in compliance. All involved, including ACGME officials, acknowledge that the guidelines have had some negative consequences and that there have been intentional violations of the work-hour standards.

But overall, ACGME Executive Director David Leach, MD, said the response from programs had been amazing.

"We think the community has risen to the challenge," he said. "They are taking it seriously."

The new standards require all residents to work no more than 80 hours per week, averaged over a month, with call no more than every third night.

In-hospital call is limited to 24 hours with an additional six hours for patient transfers and educational activities. One day off out of seven, for an average of four days off a month, also is required.

Of the 7,964 programs the ACGME accredits, 1,753 were visited in the past 11 months, and 84 were cited for problems related to work-hour violations, the ACGME said.

A stiff penalty

"Duty hours are being met," Dr. Leach said. "The financial incentives are too heavy to risk having your accreditation withdrawn."

Robert Phillips Jr., MD, MSPH, the assistant director of the Robert Graham Center, which looks at primary care policy issues, said the penalty's severity is counterproductive to the goal of enforcement.

"Losing accreditation has lots of repercussions, from [Medicare] payments to the board eligibility of your graduates," he said. "It carries a stigma. To be a top program and lose accreditation is just damaging."

And that, he said, could keep residents from revealing violations. "Residents are under intense pressure to suck it up," he said. "The ACGME relies on the residents to tell them when there is a problem, and in many cases when residents do it, they bear the cost."

Dr. Phillips suggested that residents be surveyed after they graduate, when they're no longer vulnerable to retaliation.

Mark Levy, executive director of the Committee of Interns and Residents, agreed that the threat of loss of accreditation keeps residents silent about hours violations.

"Residents fear retribution from the hospital, from other residents," he said. "They fear losing accreditation and for their futures as physicians."

Levy would like to see an independent group monitor hospitals with unannounced visits, as in New York, where individual program's citations are made public.

Anecdotal reports from residents indicated that they, too, would like to see changes in how the work-hour standards are administered.

Many said programs were implementing the standards but were violating the spirit of the rules.

Instead of finding ways to free residents from time-consuming clerical duties, some programs were cutting back on time spent at educational activities.

An informal survey by the Assn. of American Medical Colleges found that the 10-hour rest period after in-hospital call was a challenging requirement to meet, because educational activities often take place when residents who were finishing 30 hours of call should be heading home for a 10-hour break.

A lack of investment in making patient care more efficient was another common complaint, as was facing tacit or explicit pressure to lie about excessive hours.

Residents said the real standards they must meet are of the physicians around them, which often don't mesh with ACGME rules.

One resident, who asked not to be identified, detailed a workweek of more than 100 hours.

As a chief surgical resident, he makes sure that the residents under him leave after 24 hours of in-house call and that their weekly schedules comply with the 80-hour average, but he isn't able to follow the same schedule.

"The bottom line is, all the patients on the service are my responsibility, 24/7," he said. "If something goes wrong, if there are problems with a patient, I can't say my hours are up. There's no one else to sign out to."

The program director and attending physicians are willing to look the other way. "They expect residents will take care of the patients," he said. "In return they train you. That's how it works."

Indeed, despite the new regulations, residents are expected to keep pace with the workload. Attending physicians worked unending hours as residents, and the new work rules don't fit in with their idea of professionalism.

"It's not cool to leave, to just sign out," the resident said. "You are seen as irresponsible if you leave."

No one asks him how long he works, and he fudges the monthly logs he turns in, recording 12-hour days instead of the actual 15, a practice not uncommon among residents.

The ACGME is aware of these problems, having seen some of these issues on its site visits.

Dr. Leach said programs following the letter of the law but not its intent could be found in violation of standards for such things as service or education.

The ACGME also does a computer analysis of a program's information to look for signs of falsified data. And it is in the process of implementing an annual electronic survey of programs and residents to probe hours and education issues.