Being a new member of this forum, I'm just getting caught up, so I apologize for responding late to this thread.
The group will be pleased to know that the AMA is finally joining the fray on Work Hours and Work Environment reforms, however belatedly. In the last year, multiple reports were released by both the Resident and Fellows Section of the AMA as well as the Council on Medical Education. The general position has been to try to achieve enforcement of work environment and work hours through the ACGME and its Residency Review Committees. Having friends on these committees which accredit residencies (ever wonder who puts a program on probation? It's these people) they tell me that work hours is a major focus.
The AMA also also pushed the concept of using the JCAHO which accredits hospitals to include work hours and conditions in its accreditation procedures.
In the last meeting, the AMA has relented to the concept that legislation may be necessary at some point, although the general feeling is that this is a last resort.
Why? Well, first and foremost, there is no evidence that 80 hour is the safe or "right" number of hours for any specialty, and it is highly likely that for some specialties it is ok, and for others it isn't. To help answer those questions, the ASM (Association of Sleep Medicine) has been starting up studies. Secondly, the AMA-RFS wants to ensure that in the cut back in hours, the education that residents are there for is not lost. If we are going to shorten hours, residents should be spending those hours taking care of patients and learning, NOT drawing blood and transporting patients. Without protections for the work environment to ensure education, it would be hard to support any strict limits on work hours. Third, a hard limit on hours is difficult to reconcile with most people's conception of the duty to the patient. In other words, we all agree that a surgeon should never walk out in the middle of a surgery when he or she reached the 80th hour assuming that the surgeon is able to continue on, the corollary is that, if at the 70th hour, they are unable to go on, they need to be professional enough to call in back-up or try to find someone else to take over. (For those of you who don't think this would ever happen, I assure you that it can and should!)
So why not federal regulation? Well, basically, it is doubtful that any regulation, no matter how well constructed will ever be able to cover all the circumstances needed to take care of patients in the most _professional_ way possible, so by bringing it back into the profession and putting some teeth into the ACGME/RRC mechanism we might be able to achieve more precise regulation. For example, if each program's FREIDA file or ACGME file was annotated with the work hours violations of that program, pretty soon medical students would wise up, and avoid those programs (they already avoid the "malignant" programs and that's just on rumors!). Over time, programs would either have to justify the hours that they are requiring (e.g. the education is just outstanding) or ratchet down the hours. Either way, residents benefit.
Finally, to address the question of a student group (AMSA) pushing this, I believe they have brought some valuable fire to this issue, however, it is difficult as some other posters have noted, to take a group, primarily made up of people who have not yet reached this stage in their training yet, seriously as the leader.
For those interested in what the current rules by RRC's are and how well programs are complying and the improvement that is taking place with the new focus on hours, here you go.
Appendix:
Work Hours – Graduate Medical Education Directory, 2000-2001
Allergy and Immunology (Revised 1996)
? No more than 80 hours of hospital duties per week when averaged over 4 weeks
? On average at least 1 full day out of 7 free of hospital duties
? On call in hospital no more often than every third night
Anesthesiology (Revised 2000)
? 1 full day out of 7 free of program duties
? On average, on call no more than every third night
Colon Rectal Surgery (Revised 2000)
? On average, excluding exceptional patient care needs, residents have at least 1 day out of 7 free of resident responsibilities
? On call in the hospital no more often than every third night
Dermatology (Revised 1999)
? When averaged over 4 weeks, residents should spend no more than 80 hours per week in hospital duties
? On average, have the opportunity to spend at least 1 day out of 7 free of hospital duties
? On call no more often than every third night
? Opportunity to rest and sleep when on call for 24 hours or more
Emergency Medicine (Revised 2000)
? 1 full day in 7 days away from the institution and free of any clinical or academic responsibilities
? While on duty in the emergency department, residents may not work longer than 12 continuous scheduled hours
? There must be at least an equivalent period of continuous time off between scheduled work periods
? A resident should not work more than 60 scheduled hours per week seeing patients in the emergency department and no more than 72 duty hours per week
(Duty hours comprise all assigned clinical duty time and conferences, whether spent within or outside the educational program, including on-call hours)
Family Practice (Revised 2000)
? At least 1 day out of 7, averaged monthly, away from the residency program
? On-call duty no more frequently than every third night, averaged monthly
Internal Medicine (Revised 2000)
? When averaged over any 4-week rotation or assignment, residents must not spend more than 80 hours per week in patient care duties
? Residents must not be assigned on-call in-house duty more often than every third night
? When averaged over any 4-week rotation or assignment, residents must have at least 1 day out of 7 free of patient care duties
? During emergency medicine assignments, continuous duty must not exceed 12 hours
? Emergency medicine or night float assignments must be separated by at least 8 hours on non-patient-care duties
Internal Medicine Subspecialties (Revised 1998)
? When averaged over any 4-week rotation or assignment, residents must not spend more than 80 hours per week in patient care duties
? Residents must not be assigned on-call in-house duty more often than every third night
? When averaged over a year, excluding vacation, residents must be provided with a minimum of 48 days free of patient care duties, including home-call responsibilities
Medical Genetics (Revised 1999)
? On average, at least 1 full day out of 7 free of hospital duties
? On call no more often than every third night, except in the maintenance of continuity of care
? There should be adequate opportunity to rest and to sleep when on duty for 24 hours or more
Neurological Surgery (Revised 1999)
? On average, excluding exceptional patient care needs, residents have at least 1 day out of 7 free of routine responsibilities
? On-call in the hospital no more often than every third night
Neurology (Revised 2000) and Child Neurology (Editorial Rev 1999)
? Residents must be allowed to spend an average of at least 1 full day out of 7 away from the hospital
? Residents must provide on-call duty in the hospital, but no more frequently than an average of every third night
Nuclear Medicine (Revised 1998)
? All residents should have the opportunity to spend an average of at least 1 full day out of 7 free of hospital duties
? Assigned on-call duty in the hospital no more frequently than, on average, every third night
Obstetrics and Gynecology (Revised 2000)
? On the average, no more often than every third night
? On the average, at least 1 full day out of 7 away from program duties
Ophthalmology (Revised 1999)
? When averaged over 4 weeks, residents should spend no more than 80 hours per week in patient care activities
? On average, have the opportunity to spend at least 1 day out of 7 free of patient care activities
? No more often than every third night
Orthopaedic Surgery (Revised 1997)
? On average, excluding exceptional patient care needs, residents have at least 1 day out of 7 free of routine responsibilities
? On call in the hospital no more often than every third night
Otolaryngology (Revised 1996)
? On average, at least 1 full day out of 7 free of hospital duties
? On call in the hospital no more than every third night, except in the maintenance of continuity of care
? Adequate opportunity to rest and to sleep when on duty for 24 hours or more
Pathology (Revised 1989)
? On average, have the opportunity to spend at least 1 full day out of 7 free from hospital duties
? On call no more often than every third night
Pediatrics (Revised 2000)
? A monthly average of every third to fourth night for inpatient rotations requiring call
? Call may be less frequent for outpatient or elective rotations
? Call-free rotations should not exceed 4 months during the 3 years of training
? A monthly average of at least 1 day out of 7 without assigned duties
? Emergency department shifts should not exceed 12 hours, with consecutive shifts separated by at least 8 hours
Physical Medicine and Rehabilitation (Revised 2000)
? Residents at all levels, on the average, should have the opportunity to spend 1 full day out of 7 free on inpatient and outpatient care duties
? On average, should be on night call no more often than every third night
Plastic Surgery (Revised 1994)
? On average, excluding exceptional patient care needs, residents have at least 1 day out of 7 free of routine responsibilities
? On call in the hospital no more often than every third night
Preventive Medicine (Revised 2000)
? When averaged over 4 weeks, residents should spend no more than 80 hours per week in all duties
? On average, have the opportunity to spend at least 1 day out of 7 free of hospital duties
? On call no more often than every third night
? Adequate opportunity to rest and sleep when on call for 24 hours or more
Psychiatry (Revised 2000)
? One day out of 7 free of program duties
? On average, on-call duty no more than every third night
Radiology-Diagnostic (Revised 1998) and Subspecialties (Revised 1994)
? Allowed to spend at least 1 full day out of 7 away from the hospital
? Assigned on-call duty in the hospital no more than, on average, every third night
Radiation Oncology (Revised 2000)
? Residents be allowed to spend, on average, at least 1 full day out of 7 away from the hospital
? Not be assigned on-call duty in the hospital more frequently than every third night
General Surgery (Revised 1998) and Subspecialties (Revised 1996)
? On average, excluding exceptional patient care needs, residents have at least 1 day out of 7 free of routine responsibilities
? Be on call in the hospital no more often than every third night
? Distinction must be made between on-call time in the hospital and no-call availability at home and their relation to actual hours worked
Thoracic Surgery (Revised 1992)
? Duty hours and night and weekend call for residents must reflect this concept of longitudinal responsibility for patients by providing for adequate continuity of patient care. At the same time, duty assignments must not regularly be of such excessive length and frequency that they cause undue fatigue and sleep deprivation
? On average, excluding exceptional patient care needs, residents have at least 1 day out of 7 free of routine responsibilities
? On call in the hospital no more often than every third night
Urology (Revised 1996) and Pediatric Urology (Revised 1998)
? On average, have the opportunity to spend at least 1 full day out of 7 free of scheduled hospital duties
? On call in the hospital no more often than every third night, except for the maintenance of continuity of care
Transitional Year (Revised 1999)
? In-hospital duty hours shall correspond to the program requirements of the categorical programs to which the transitional year resident is assigned
? Distinction must be made between on-call time in the hospital and on-call availability at home vis-?-vis actual hours worked
? On average, excluding exceptional patient care needs, residents have at least 1 day out of 7 free of routine responsibilities
? On call in the hospital no more often than every third night
Source: Graduate Medical Education Directory, 2000-2001
Appendix 2
ACGME
NUMBER OF PROGRAMS AND INSTITUTIONS CITED FOR WORK HOURS AND RELATED REQUIREMENTS FOR YEARS 1999 and 2000
Specialty % Progs Cited1999 %Prog Cited2000
INSTITUTIONAL REVIEW 20.0% 8.0%
Allergy and Immunology 22.0% 8.0%
Anesthesiology 2.0% 2.0%
Colon and Rectal Surgery33.0% 6.0%
Dermatology 7.0% 0.0%
Emergency Medicine 10.0% 6.0%
Family Practice 13.0% 8.0%
Internal Medicine (Core)30.0% 10.0%
Subpecialties 4.0% 2.0%
Medical Genetics 6.0% 0.0%
Neurological Surgery 10.0% 5.0%
Neurology 14.0% 14.0%
Nuclear Medicine 0.0% 0.0%
Obstetrics and Gynecology19.0% 5.0%
Ophthalmology 13.0% 0.0%
Orthopaedic Surgery 29.0% 10.0%
Subspecialties 10.0% 4.0%
Otolaryngology 10.0% 3.0%
Anatomic and Clinical Pathology
20.0% 2.0%
Subspecialties 6.0% 2.0%
Pediatrics 21.0% 16.0%
Physical Medicine and Rehabilitation 12.0% 12.0%
Plastic Surgery 10.0% 10.0%
Preventive Medicine 0.0% 0.0%
Psychiatry 0.0% 0.0%
Radiology-Diagnostic 0.0% 1.5%
Radiation Oncology 0.0% 0.0%
Surgery-General 36.0% 35.0%
Vascular 17.0% 9.0%
Pediatric 53.0% 44.0%
Thoracic Surgery 16.0% 21.0%
Urology 8.0% 2.7%
Transitional Year 24.0% 23.0%
5/9/01
Source: <a href="http://www.acgme.org," target="_blank">http://www.acgme.org,</a> accessed June 25, 2001
