Reducing resident work hours moving to forefront of national scene

But which plan, governed by which agency, will end up in place?

Issue: March 2003

NEW ORLEANS — It is not often that orthopedic surgeons think of their days in residency as “the good, old times.” Traditionally, residency has been associated with 100-plus hour workweeks, 36-hour shifts and, naturally, very little sleep.

But is the exhaustive training schedule safe?

It is that question which has grabbed the attention of the public, due in large part to articles in the lay press. In turn, considerable pressure has been put on both the medical and federal community to reduce the burden placed on residents and allow them to have more time off to get more rest, in theory.

And while the literature supporting reduced resident work hours is very limited — Jack Choueka, MD, chief of hand and upper extremity surgery at Maimonides Medical Center in New York, said he found just 97 Medline references to the issue compared to 25,000 for osteoarthritis — the current of change is steaming forward.

Work hours restrictions have been in place in New York since the late ‘80s (although they have only been recently enforced) and will be introduced in some form nationwide in July.

As training programs scramble to implement a workable system, a symposium at the American Academy of Orthopaedic Surgeons 70th Annual Meeting was convened to discuss the history of resident hours and ways that hospitals might best find a feasible (and legally compliant) schedule.

“This is not something you can argue away,” said Neil Cobelli, MD, chairman of orthopedic surgery at Montefiore Medical Center in New York. “It’s probably a good thing overall. The mistake we made in New York was ignoring it for the first 10 years so that now we’re given absolutely no leeway from the enforcement agency.

“If you want to gain anything from our experience, learn to embrace these changes. Put your own systems into place, utilize your exceptions and try to protect your didactic sessions.”

The roots of the debate on resident work hours can be traced to March 4, 1984, when 18-year-old Libby Zion was admitted to Cornell University’s Medical Center in Ithaca, N.Y., with a high fever. She was dead a day later.

Zion’s case reached the national spotlight because her father, Sidney Zion, a reporter with the New York Times, exposed the practice of residents working for more than 100 hours a week with shifts upward of 30 consecutive hours.

And although there was a $700,000 award for liability, this case obviously uncovered problems with the residency system. Eventually, an advisory committee headed by Bertrand Bell, MD, then a professor of medicine at Albert Einstein College of Medicine in New York, was created.

In 1989, the Bell Commission’s recommendations — which included limiting residents to 80 hours per week in the hospital averaged over a four-week period and mandatory rest periods — were introduced into the New York State Health Code.

Prior to investigations by the Island Professional Review Organization (IPRO) in 1998, however, most medical training programs ignored the regulations. IPRO found that almost every program it investigated was in violation of the statutes and fined them accordingly.

After these investigations, most residency programs were revised, although some continued to violate the statute.

Making adjustments

So what sort of changes were made?

At Montefiore Medical Center, where Cobelli oversees the orthopedic residency program, a night float system was introduced.

In the night float system, instituted in 2001, second call was almost entirely eliminated. Post Graduate Year (PGY)-2 residents take first call, working one 24-hour shift and one 12-hour shift during the week, and serve on night float on Fridays and Saturdays. Four hours of transition time are also used.

PGY-3s also periodically end up on first call.

“Night float is completely predictable and compliant with regulations,” Cobelli said. “It removes the pressure on junior residents to remain after they’ve had a rough night.

“It’s absolutely improved patient-care continuity. Instead of having us with a resident in hospital A covering a night in hospital B and leaving a note for the team coming in during the morning saying, ‘This is what happened the night before,’ it’s the same team rounding morning and night. It’s an integral member of the team who cares for each patient and knows each patient’s condition moment to moment. I can think of one case in particular where a person’s life was saved because of the night float resident being aware of their condition.”

But there are also downsides, Cobelli said. Residents’ interaction with attending physicians is limited unless there are emergencies during first call. In addition, the odd shifts interfere with the residents’ internal clocks. Also, the elimination of second call required the hiring of several physician assistants at a cost of close to $500,000 per year, almost the entire orthopedic training budget.

Still, Cobelli said the changes have had a positive overall effect on the resident experience.

“The residents still seem to attain the necessary surgical skill,” Cobelli said. “Yes, they’re still tired and they’re still sleeping through lectures, but these changes are necessary.”

While New York sprang into action more than a decade ago, it took longer for national organizations to gather enough support to institute change.

Finally, in September 2001, the Accreditation Council on Graduate Medical Education (ACGME) devised its own set of standards slated to go into effect in July.

The ACGME standards are similar to those in place in New York, with minor adjustments made in scheduling requirements. The major difference is that medical schools, not individual hospitals, must ensure that residents are in compliance. Schools found non-compliant can lose their accreditation.

“Compliance with ACGME guidelines is feasible,” Choueka said. “They are practical.”

The ACGME standards, however, may never go into effect — not if the federal government steps in with standards that surgeons like Choueka find far less palatable.

In 2001, a bill addressing residents work hours — titled The Patient and Physician Safety and Protection Act — was drafted by Sen. Jon Corzine (D-N.J.) and Rep. John Conyers, Jr. (D-Mich.). It has yet to go to a vote, but when it does, it will go into effect the first July after potential passage.

The federal bill is more restrictive and includes harsher penalties than either the Bell restrictions or the ACGME proposal.

Because of the restrictions and unspecified areas (moonlighting, patient transfer allowance), there are many senior attendings who feel that the federal legislation is impractical.

“I think that bill is very scary because it is not a well put-together bill and it is not well defined,” said Allan Strongwater, MD, director of orthopedic surgery at Maimonides Medical Center in New York. “I’m not sure it would even exist were it not for sentiment and politics. But if it went to vote today, it would be a very close call.”

For your information:

Strongwater A, Cobelli N, Choueka J. Resident work hours — Where do we draw the limit? Presented at the American Academy of Orthopedic Surgeons 70th Annual Meeting. Feb. 5-9, 2003. New Orleans.