Otolaryngologists View Resident Work-Hour Restrictions: ACS calls for in-depth investigation before mandating further restrictions

In addition, although the ACGME has defined time off as a period free from all residency training requirements, including clinical, administrative and educational activities, there is no clear way to ascertain whether trainees are truly using these free periods to rest or are engaged in other professional activities, such as moonlighting.

New models have been proposed and implemented to comply with work-hour restrictions, and the need to meet the new regulations has steered residency programs to explore a variety of creative approaches. These include a day-float or night-float system, recruiting physician extenders, increasing cross-coverage of patients, eliminating or streamlining services, better using information technology, and requests to the residency review committees to increase the resident complement.12 Some residents have been pulled from clinical sites to cover patient care responsibilities, or senior residents have had been asked to pick up slack for junior residents. Also, attending physicians have often needed to fill in the gaps. The selection of different models has been based on local factors, availability of resources, and the nature of the clinical service, said Dr. Sachdeva. But regardless of the model that is selected, unless the entire educational program is restructured with different educational approaches and interventions, the residents may not receive the requisite education and training.12, 14

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Figure. The ACGME has introduced explicit regulations for residency training, designed to ensure that residents are sufficiently rested when caring for patients, but questions remain as to the benefits of the work-hours restrictions.

The financial costs engendered by these restrictions are significant and, for the most part, not compensated. These costs include the necessity of hiring additional physician extenders that many institutions cannot afford.

Another big question, said Dr. Sachdeva, is: Are we training residents appropriately regarding professionalism and patient care responsibilities, or are we moving toward training them as shift workers, regardless of patients’ needs?

Although there may be some gains in patient safety from the work-hour restrictions, this might also be offset by the inherent dangers in increasing the number of transfers of care. Gerald B. Healy, MD, Chief of Otolaryngology at Children’s Hospital in Boston, pointed out that in his institution, five different residents may handle the patient’s care from initial diagnosis to post surgical discharge, leading to what may well be piecemeal education, reduced continuity of care, and increased risk for error and consequent adverse events. There is one fundamental question that has to be answered in this whole paradigm, said Dr. Healy. If you are a patient coming to me for care, are you better off being taken care of by a well-rested doctor who is not very familiar with your case, or by a fatigued doctor who is very familiar with your case?

ACS Position and Recommendations

The American College of Surgeons (ACS) appointed a special Task Force on the 80-hour workweek, under the leadership of L. D. Britt, MD, MPH, now Chair of the ACS Board of Regents. The ACS Task Force reviewed the available evidence relating to this subject and made the recommendation that the impact of the 80-hour workweek needs to be comprehensively studied before any further reductions in work hours are considered.