Hospital Accreditor Will Strictly Limit Hours of Residents By LAWRENCE K. ALTMAN and DENISE GRADY In a move that is expected to make a significant change in the way doctors are trained, the group that accredits the nation's teaching hospitals said yesterday that it would impose strict new limits on the number of hours worked by medical residents. The rules, intended to reduce the risk of dangerous errors by sleep-deprived young doctors, are to take effect in July 2003. They will limit the workweek to 80 hours, require at least 10 hours of rest between shifts, restrict duty to no more than 24 hours at a time and restrict work outside the hospital. Advertisement They will also require stricter supervision and accountability from the hospitals that train the residents. Faculty members and program directors will be required to assess the residents for signs of sleep loss and fatigue. Residents are newly minted doctors who spend three to seven years training as specialists in hospitals after they earn a medical degree. Many of the nation's 100,000 residents complain that they now work 100 or more hours a week. Some specialties like internal medicine and emergency medicine have already limited residents' workweek to 80 hours. But the new working-hour rules are the first ever imposed on all specialty training programs by the Accreditation Council for Graduate Medical Education, an organization in Chicago that monitors the training of residents in 114 specialties in 7,800 programs throughout the country. New York is the only state with a law limiting such work hours, to 80 a week for all residents. The council's action coincides, however, with the introduction of federal legislation by Senator Jon Corzine, Democrat of New Jersey, and Representative John Conyers Jr., Democrat of Michigan, that would also limit residents' hours. Concern about residents' schedules has intensified, the council noted, now that hospitals are under ever greater pressure to discharge patients quickly as a way to control costs. Responding to the new rules, a union representing residents said the council had done little to enforce existing rules that it adopted in the 1980's. Those rules say residents should get at least one day off in seven and be on call no more often than every third night. The union's national president, Dr. Ruth Potee, said the council had "come a long way in this year in recognizing that residents' hours are extreme" and was now "closer to where we'd like them to be." But she added that the union was not happy with a provision of the rules that will allow hospitals to increase the 80-hour week by 10 percent if they can justify doing so on educational grounds. "We feel strongly that 80 hours a week is truly the limit," said Dr. Potee, a family medicine resident at Boston Medical Center. Dr. Potee said some residents now worked 120 hours a week. Hours tend to be longest, she said, in surgery, obstetrics and gynecology, and family medicine. Her union, the Committee of Interns and Residents, has about 12,000 members ? some 10 percent of the nation's residents ? and is affiliated with the Service Employees International Union, the largest union in the A.F.L.-C.I.O. Among the groups represented on the accreditation council are the American Hospital Association, the Association of American Medical Colleges, the American Medical Association and the American Board of Medical Specialties. Dr. David Leach, the council's executive director, said it intended to enforce the new rules aggressively, using confidential Internet surveys of residents to find out whether hospitals are violating them. Reports of egregious violations could lead to a quick visit to the hospital to evaluate them on site, he said. Violations could be costly: a training program might be stripped of accreditation. If so, the hospital would lose some of its reimbursement from Medicare and Medicaid. In addition, doctors cannot be certified as specialists unless they graduate from a training program that is accredited. Last month the council threatened Yale-New Haven Hospital, a teaching affiliate of the Yale School of Medicine, with loss of accreditation of its surgical program because residents were on call too many nights and were working weeks of 100 hours or more. Although existing rules place no specific limit on the workweek of surgical residents, in general the council can act when it finds that a hospital has breached the rules' spirit. In any event, the new changes "will force a redesign of the entire training system," Dr. Leach said. Strict compliance with the rules could increase teaching hospitals' costs by millions of dollars, since those hospitals often rely on residents as a source of low-cost labor. In separate interviews, Dr. Leach and Dr. Potee noted that budget constraints had forced many teaching hospitals to reduce their staffs, including nurses and workers who draw blood and move patients. Although many hospitals have hired aides called "physician extenders" to help with such work, much of the burden has fallen on residents, increasing their hours and interfering with their education. In 1999, the Institute of Medicine of the National Academy of Sciences issued a report citing evidence that medical errors in hospitals killed 44,000 to 98,000 people a year. A number of experts have come to believe that most medical errors result from systemic flaws in the way hospitals, clinics and pharmacies operate, not from individual recklessness. Training programs are part of the larger system, and the council wanted to fix its part of the systemic problem, Dr. Leach said. The rules will have a big effect on surgery because that specialty has not set workweek limits on its own. Leading surgical educators recognize that patients have a right to an alert physician to deliver appropriate care. But they also say surgical training requires a commitment to continuity in patient care, regardless of the time of day, number of hours already worked or on-call schedules. Standards set by the surgical specialty specified only that surgical residents were supposed to spend at least one day out of seven free of hospital duties and not be on call any more than every third night. There were a variety of reasons for the absence of a maximum workweek. One was the widely accepted belief that the more often a surgeon does a procedure, the better the performance. In their desire to do as many operations as possible, surgical residents have tended to stay at the hospital longer to get the experience. Another reason was the importance of continuity in patient care. Surgeons have felt a heavy obligation to stay with a patient, particularly if a complication arises, until they recover. Although New York State limits all residents to an 80-hour workweek, the accreditation council's surveys have found those regulations "were not all that effective," Dr. Leach said. But, he said, in recent months New York had stepped up the enforcement and fines associated with the regulations.