I'd like to make it clear. I do not support an arbitrary limit on maximum hours be it 56 or 84 or whatever. I stayed long past the hour limit from time to time when I was scrubbed on an interesting and educational case. But this was at a program that followed the ACGME rules, to the letter, was extremely interested in the highest quality resident education and managed its program well. Residents were not used for clerical work and when a chief ordered me to pull 30 sets of films for a clinic in front of the attending, the chief got a royal chewing for not using appropriate clinical support staff for this purpose. (Natch, the chewing came back to bite me since it was my fault the chief used bad judgement). But, I didn't pull films that day or any day after that, which allowed me to concentrate on the consults/follow ups of the day and not waste an hour getting films. These are the kinds of things that hospitals are accustomed to wasting residency time on.
Progress notes: every note has to have every detail written, even though lab values/vital signs are readily available in computers everywhere these days, yet residents in some specialties still write a page and a half note every day on stable patients. Why? If it's so important to paste values in the chart note, have the clerk print the lab values and vitals on sticky lables, paste 'em in a progress note for the resident/attending to review and write your note around that. More work for unit clerks/nurses? Yup, but it makes rounding much faster and more efficient, again freeing up time for more educationally productive endeavors. One thing that amazed me more than anything about the medicine services at some institutions: Many, many centuries ago, monks copied books by quill. We knew this was inefficient and invented the printing press and the xerox. Why are we still doing this in medicine? This is one of PandaBear's peeves, and I agree.
Again, I have no problem with the present 80 hour or 88 hour week, if it can truely be justified. Other professionals do it. We can too, safely. But and this is a huge caveat, working consistent, regular, extremely extended shifts is unhealthy, not educational, and not wise. This is the problem with the hospital abuses of residency education for busy work/clerical work. An occasional unplanned 24 or even 30 hour stretch for unique circumstances is probably reasonable. But this should be an exception for exceptional circumstances: The simple fibroid hysterectomy that turns out to be cancer and a short surgery is now an all day event comes to mind. Or the nasal pharynx resection that is a scheduled all day (15 hour) case. These are the type educational experiences that warrant exceptions. Not admitting the tenth chest pain patient of the day.
The problem is that some hospitals have not been willing to be reasonable. Then the unique learning opportunity becomes a scheduled service resulting in the mess we had before the ACGME was finally forced to self-police or face congressional action.
Some institutions, have taken the 80 hour week and its philosophy to heart, worked diligently to build a reasonable schedule which does not require excessive fatigue and is highly humane. These are great places to do residency, even though the work is hard, and the hours are still long. What I have been told by program directors/chairs from those institutions is their residents peform better, learn more and are prospering.
Others have viewed the 80/30 hour rule as a regulatory burden and have made few changes other than to bring things into nominal and "loose" compliance. Residents in these institutions fare less well. These are the institutions would be targetted by the AHRQ recommendations.
For me, I'd be satisfied with having no particular cap, but mandating 10 hours per day rest, averaged over a 7 day period, with a maximum on duty time of say 18 hours. This would still leave at a minimum, 6 hours of rest, would allow over 90 hours if a particular educational situation demanded it, yet, would insure that residents got at least marginally adequate daily rest. Make it an 80 hour week, and the numbers change to 12 hours rest per day averaged over a 7 day period. Wait, isn't that what EM does now? And they didn't extend their residency!