Whether you want to believe it or not, many training programs are in violation of the ACGME duty-hour standards. I’ve known this all along, primarily from talking with many people in residency that I keep in touch with on a regular basis.
The AMA has released a study that basically proves that the work hour standards are one big piece of political bullshit.
The study was a monthly web-based survey, and polled residents preimplementation and postimplementation of the work hour standards. The residents taking part in the survey completed 29,477 reports of their work and sleep hours.
Violations were reported during 3765 (44.0%; 95% CI, 43.0%-45.1%) of the 8553 intern-months assessed postimplementation (including vacation and ambulatory rotations), and during 2660 (61.5%; 95% CI, 60.0%-62.9%) of 4327 intern-months during which interns worked exclusively in inpatient settings.
There you have it, folks. Nearly half of all months had violations during ambulatory settings and nearly 62% of months had violations where interns were working on inpatient services.
The ACGME needs to start cracking some balls if they want programs to take these duty restrictions seriously. If nothing is done, or programs are simply slapped on the wrist, the system will continue to be abused and work hour restrictions will be nothing more than fudged numbers on some slip of paper in the program director’s office.
via: [JAMA]
What do you think will actually be done?
I don’t know, but I hope (for residents’ sake) that these violations are taken seriously and programs start getting slapped with punishments.
jama, huh? great post!
I bet these violations are grossly underreported and the real percentage is much higher. For surgery, it’s probably more than 95 percent.
Probably so Zuwie. The study didn’t state which specialties were polled. With “ambulatory” and “inpatient” services, though, it sounds as if the bulk of the data came from medicine rotations.
With answers like what they are getting, they should dig further.
Who provides a solution? Protesting med students, some MBA who has a panic attack seeing that you are out of compliance? Once someone brings the to the attention of a supervisor or administrator, they become liable.
Some lawyer or budding politician needs to jump on this to make a name for his or her self.
Oh– and since we have a shortage of MDs in the US, and from what you say here about people being stretched beyond normal working conditions, why aren’t there more doctor slots? Med school attacks the best– excuse me, ATTRACTS the best– it’s not like each school admitting ten more students will be scraping the bottom of the intellectual barrel.
During my surgery internship, we reported our work hours to the department secretary. I was hauled into the Program Director’s office where he and the Chairman of the department ORDERED me to lie on my hours report. I was to write no more than 80 hours on my timesheet. Apparently all the other interns were already doing that so I was the outlier who was actually telling the truth. I participated in the study you quote and I averaged 105-110 hours per week for 50 out of 52 of those weeks. The other 2 were vacation.
“A doctor must work eighteen hours a day and seven days a week. If you cannot console yourself to this, get out of the profession.”
Martin, that’s absurd. Who came up with that canard?
I guess nobody should be a doctor then, because out of the hundreds of other attending physicians I know and work with on a daily basis (including OB-Gyns, neurosurgeons and other subspecialty surgeons) a whopping total of NONE of them consistently work the hour equivalent of 18 hour days 7 days a week. The only physicians I know of who do this consistently are medical residents.
Yes, an occasional 125+ hour work might happen in busy specialties under unusual circumstances, but so far as I can tell, this is the exception, not the rule. I have yet to encounter any physician who works 125+ hours every single week once their training is done, or wants to, let alone considers a routine like that “normal”. I do know plenty of top tier physicians (and not-so-great) ones who actually would leave medicine if forced to consistently physically work 125+ hours per week.
And that’s a GOOD thing. What kind of medical judgment do you think someone has after being chronically sleep-deprived and working non-stop like a dog for several months on end? Do you think someone in that position is going to give the best possible medical care? Do you want EVERY physician to be divorced, angry, bitter, overstressed, and overworked? How is that good for ANYONE?
Physicians are still human beings who need rest, entertainment, family and social lives. . .yes, even for the 3-7 years while they’re in training.
As to the ACGME requirements, its 2011, and my understanding is that ACGME duty hour requirement violations are still common in various medical specialties, especially (but not limited to) surgical ones.
In terms of enforcement, this has be put in perspective. The ACGME oversees literally 7500+ different American medical training programs in over 100 specialty areas. With them generally reviewing programs only once every 3-4 years, their enforcement ability is necessarily limited.
Its my understanding that the ACGME has actually increased citation of programs in violation of the duty hour requirements, especially in the last 2-3 years (since 2009), and they’ll prioritize investigation of programs if formal complaints have been made. But the ACGME is in a tough spot too. While in theory it could shut down programs for non-compliance, in practice, doing so would be most harmful to the individuals it would nominally supposed to be helping. .. the medical residents themselves. If the ACGME did shut down programs, its non-graduating residents would find themselves out of jobs at the end of the year. These now ex-residents would have to scramble to find other level appropriate accredited training positions in their specialties. . .something that would at BEST be highly inconvenient, likely requiring short-notice relocation to a different part of the country, and more probably be literally impossible in any truly competitive specialty.
I think most residents would rather suffer with a few extra work hours per week for a few years, instead of give up on their respective specialties altogether and have to start training again from scratch!
Lastly, and most important, newly graduating physicians aren’t babies and they aren’t exactly idiots. The overwhelming majority of senior medical students have a pretty good idea going into their respective residencies exactly what the expectations will be, including knowledge of likely duty hour violations BEFORE they sign up for the match. Bluntly, there is no way anybody applying into surgery can’t be UNAWARE that duty hour violations are common, if not the norm. If you are truly that clueless applying into surgery. . .well, maybe you shouldn’t be a surgeon.
So I say, no harm, no foul. If you’re 27 and single, maybe working 110 hours a week for a few years isn’t so terrible. Most of the young surgeons I talk to are fine with this. No, they don’t love it, but they know exactly what they are getting themselves into when they sign their contracts, and they accept it as a necessary barrier to entry into the specialty. (Whether or not it “should” be is a whole other topic).
The point is, if you’re a medical student and think that a 100 hour work week for a few years isn’t for you, then ACGME rules or not. . .don’t rank a program where that’s what the responsibilities are going to be. If you want to be an OB or surgeon, etc, (or even if you dont) then it behooves you to understand what you’re getting yourself into before you sign on that dotted line.