April 2003 Bulletin

Orthopaedic residents surveyed for opinions on limiting duty hours

By Patrice Drew

The recent policy proposal by the Accreditation Council for Graduate Medical Education (ACGME) regarding resident duty hours has stirred much debate within the medical community. Some residents have argued that overwork has detrimental effects on their health and well being. Others believe that these intensive hours provide the training necessary to fully reach one’s potential as a physician. Federal and state governments have started to question the possible links between long resident duty hours and medical errors.

In response to this ACGME proposal, the AAOS Committee on Academic Advocacy, chaired by Gary Friedlaender, MD, convened a workgroup to examine this issue. Michael Sirkin, MD, a member of the Committee, initially composed and circulated a survey aimed at determining residents’ opinions on the idea of limiting their duty hours. Dr. Sirkin surveyed 87 orthopaedic surgery residents, attending physicians and fellows in November 2002. The residents were asked about their current duty hour levels and to comment on the ACGME policy.

Residents express concern

Building on the results of this survey, the committee and the AAOS Washington office initiated a broader survey e-mailed to 1,100 orthopaedic surgery residents. Of the residents surveyed, 65 percent believed that resident duty hours should be regulated, but 47 percent believed that limitations on the number of hours they could work would negatively impact their training and education.

Many residents expressed concerns over whether limited duty hours would force programs to add additional years to their residencies to compensate for missed clinical and operative experience. Other residents surveyed believed their training would be enhanced by more rest, which would lead to better retention of information and better morale among residents.

AAOS submits comments

In addition, the AAOS submitted comments to the ACGME on this policy proposal. While the AAOS strongly supports the welfare of patients and protection of a nurturing and effective training environment for residents, it was deeply concerned about Congress or any other government body placing unreasonable limitations on residents’ duty hours that might hamper the furtherance of medical education or the delivery of care.

The AAOS strongly urged the ACGME to fund the research necessary to better understand the effects of duty hours limits on patient safety and the quality of resident training.

In 2002, both the U.S. House of Representatives and the Senate considered legislation that would make the regulation of resident duty hours a Medicare-hospital condition of participation and limit residents to no more than 80 hours of work per week. In response to the possibility of federal intervention, the ACGME proposed universal standards for resident duty hours that would require residents to work no more than 80 hours per week, averaged over a four-week period.

Under the ACGME proposal, the 80-hour limit could be increased to 88 hours per week over a month if an individual residency program applied for an increase based on a "sound educational rational." Residents’ shifts would be no more than 24 hours, with the possibility of a six-hour add-on period for transfer of patient care, educational debriefing and instructive activities. Additionally, residents would be on call no more than every third night, averaged over four weeks.

The ACGME proposal would require each resident to have a minimum rest period of 10 hours between duty periods. When residents take call from home and are called into the hospital, the time they spend in the hospital must be counted towards the weekly duty hour limit. The ACGME is expected to implement its policy change later this spring.

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