Bernard M. Jaffe, MD Professor of Surgery Department of Surgery Tulane University School of Medicine New Orleans, LA

Even though the Accreditation Council for Graduate Medical Education (ACGME) work-hour regulations for residents were implemented in 2003, violations are still being reported. In reality, who imagines that it is even possible for all programs to comply absolutely with these misguided and punitive rules? Yet, total obeisance is being demanded and the occasional failures have prompted significant rebuke.

A group of Harvard physicians recently published a paper in JAMA, entitled “Interns’ compliance with accreditation council for graduate medical education work-hour limits,”* that blasts the entire residency-teaching community for the frequent deviations from work-hour regulations that a number of interns reported in responses to a questionnaire. The authors urge research to determine the causes of the reported violations.

I recognize that I am old-fashioned and was trained under a scheme in which work-hour limits were unthinkable, but I still fail to recognize any relationship between the death of a young woman in a New York hospital and the need to restructure postgraduate training completely. My initial prognostication that the furor over work-hour regulations would wane was incorrect. It is clear that these regulations are here to stay, and any changes are likely to make them more restrictive. Thus, objecting to these rules is nonproductive, and I won’t waste the emotional energy.

I will, however, take time to criticize the means of implementing the work-hour limits, the possible punitive sanctions, and the published criticisms of ‘violators.’ I have long admired the attitude of my college classmate Steve Safranko (now a successful attorney), whose traditional response to the imposition of unnecessary discipline was “needs it!”

While the 80-hour per week limit has been highly publicized, it is only one of three major components of the total regulatory package. The other two are limiting shifts to 30 consecutive hours (including education and sign-outs) and providing one day off each week. Frankly, it is difficult to argue that these are inappropriate goals. Those of us who trained in the “days of the giants” and before the death of Libby Zion did suffer unnecessarily and indisputably worked much too hard. Yet, despite everyone’s best intentions, occasional deviations from the work-hour regulations may be warranted to protect patients and provide educational opportunities. Under current regulations, such deviations are not acceptable.

As I see it, the abusive monitoring process is mired in detail. The JAMA article is a perfect example. It is hard to imagine that five scholars—four with MDs or PhDs or both—have nothing more productive to do than monitor the compliance details of these work-hour regulations. For example, how relevant is it that the mean hours of interns’ sleep increased from 5.91 to 6.27? Is that measured from when the subjects got into bed, when they closed their eyes, or when they fell into REM sleep? I don’t know about you, but there is no way I could give an accurate accounting of how long I slept at a given time. To do so, I would have to look at the clock, and that would keep me awake. The next thing these bean counters will want to know is how much time interns spend in the restroom. Will that diversion be counted as education and incorporated into the 80 hours? If eating is included within the training time, residents must learn to chew quickly to avoid using up valuable allotted time.

The ACGME processes for monitoring compliance are expensive and nonproductive. At Tulane, one secretary is employed virtually full-time distributing, collecting, and collating data on the residents’ work hours. I can think of a myriad of ways to spend resources on residency training that are much more productive.

In one New York program, trainees sign in and out with a thumbprint, as a mechanism of time keeping, a technique that is certainly objective. But this requirement lowers the professional standing of physicians, even those in training, and I hope it is not the direction in which we are all heading. Another major disadvantage of time-keeping is that it often serves as a barrier between trainees and faculty. Some residents resent being evicted from the operating room at the 30-hour mark and hold it against the attending standard-bearers who, in reality, have no option. On the other hand, many attendings do not take kindly to trainees who drop out of the operating room, clinic, or rounds because their shifts are over. Education is best served by collaboration between teacher and pupil, and rigid implementation of divisive rules jeopardizes this relationship.

There has long been controversy as to whether residents are employees or trainees in an educational program. Determining this status has significant implications in terms of level of responsibility for patients, human resource entitlements, tax status, and other variables. While time schedules and expending effort are consistent with educational objectives, quantifying, monitoring, and punishing are not. The ACGME is being duplicitous in requiring programs to provide education but micromanaging the learning environments.

Having been heavily involved in the successful evacuation of Tulane University Hospital after Hurricane Katrina, I have given a large number of instructional lectures about what lessons were learned. Since several general and plastic surgery residents played pivotal roles in our success, I routinely brag about their heroism and compliment them during these talks. I am stunned by how frequently I am asked at these activities whether residents violated their work-hour limits during these critical days. The answer is yes, of course. It was technically not permissible for them to work 24 hours each day, and without sleep, for several successive days. Yet I can assure you that despite the hardships we all endured, they learned more about what it means to be a doctor than any previous training or experience provided. The fact that the question is asked illustrates how far we have strayed from the training objectives and reality.

Yes, the work-hour limits and their implementation are mired in detail. We can salvage the process and provide a comfortable resident learning environment, but it requires significant changes. Attendings need to accept reality, modify their expectations of the residents accordingly, and plan to do more of the clinical work themselves. Residents need to step up to the plate and further focus on independent learning rather than staring at their watches. The ACGME has to relocate the big picture, recognize the educational problems the organization has inadvertently created, and become more flexible in implementing and enforcing the regulations. As for the Harvard group that wrote the JAMA paper, they would be best served by redeployment to more productive endeavors than studying and writing about inconsequential details.

Reference
*Landrigan CP, Barger LK, Cade BE, et al. Interns’ compliance with accreditation council for graduate medical education work-hour limits. JAMA. 2006;296(9):1063-1070.