Maggie is in the fifth month of her general surgery internship. She, along with the other interns, has been consistently working more than 90 hours a week even though she is aware that she is exceeding the 80-hour work week limit established by the Accreditation Council for Graduate Medical Education (ACGME). But she has enjoyed staying overtime to scrub in on interesting cases. One night, for example, at the urging of the attending surgeon, Maggie stayed late and was able to graft a saphenous vein for the first time.
Maggie recently ran into another intern, Justin, in the resident lounge. "Dr. Smith made me stay for an appendectomy post-call, and it was the fifth time this month I've stayed," he complained. "I keep falling asleep during morning conference!" After talking with other interns, Maggie discovered that they all have been working more than 80 hours a week. Some of them revealed that they felt pressured to stay and would prefer stricter adherence to the ACGME policy.
A month later an ACGME representative visited the hospital to investigate compliance with the new work hour regulations. That morning, a number of residents were told that they will be interviewed by the site visitor. The residents discussed how they would handle the interview, and some of the senior residents suggested that they lie to prevent jeopardizing the hospital's accreditation status. Maggie felt that the additional time she had spent in the hospital had been beneficial to her learning experience and that working less would have limited her education, but she also understood that she could be risking her hospital's residency program if she told the truth. Furthermore, many of the other residents may not have found the extra hours as valuable and instead have viewed the extra time as a nuisance. Maggie was still contemplating what to say when she was called for the interview.
Before discussing Maggie's very difficult situation, I would like to describe how it could have been avoided. Communication is the key to preventing the problems that arose in Maggie's program. Every month, at each of New York University School of Medicine's 3 teaching institutions, the program director and his associates meet with the residents. It is an open and frank forum in which issues ranging from work hours to faculty evaluations are discussed. The program directors stress that honest information and feedback specifically regarding work hours are critically important both for the residents and for accreditation of the residency program. They note that with reliable information they can go to the hospital administration and ask for help in the form of ancillary staff and nonphysician providers.
Program directors want to avoid any trouble with the Residency Review Committee (RRC), but they may be the only faculty at the institution who really appreciate all the RRC requirements and consequences of non-compliance. I am certain that if Maggie and some of her colleagues had first confronted the program director with the fact that some attending physicians were repeatedly pressuring residents to stay late, he or she would have put a stop to the practice. It is simply too costly in time and reputation to ignore RRC regulations.
The next intervention should have occurred at the institutional level. At NYU, the Graduate Medical Education Committee (GMEC) monitors internal medicine and surgery work hours on a monthly basis. Furthermore, it has a House Staff Affairs Committee that meets with residents to discuss issues such as work hours. Since fears of reprisal may be a concern for some residents, the GMEC installed a work hours "hotline" so that residents could inform the institution of work hour violations anonymously.
Unfortunately the above steps were not taken in the case at hand, and Maggie clearly has a dilemma. Her concerns are not limited to the program's possible loss of accreditation status but extend to personal reprisals from the training program. The loss of accreditation hurts the program, and it may require that Maggie and her fellow residents transfer to a different program if the institution is not rapidly reaccredited. Quite frankly, Maggie has no easy answers to her problem.
The residency program is completely at fault in Maggie's case and should be cited for work hour violations. There is no excuse for the flagrant disregard of the rules. Furthermore, the institution at large shares part of the blame for not monitoring the department of surgery. The citation may result not in loss of accreditation but in a warning and shorter review cycle. Maggie must recognize that her program will have to comply or face censure sooner or later, but whether it is in her best interest to bring the situation to light is, unfortunately, another story.
Maggie did and still does have the opportunity to report work hour violations anonymously to the ACGME and they will do their best to protect her identity. She may not feel comfortable disclosing her knowledge of the situation before a large group, but she can and should inform the ACGME of the repeated violations either before or after the visit.
I must add that I disagree with the work hour regulations as they are now enforced. I firmly believe that both education and professionalism have been diminished by the new rules . The evidence that patient care is improved by reduced work hours is very limited, and the recent articles in the New England Journal of Medicine did little to resolve the issue of balancing the new regulations with learning . Furthermore, it has been my experience that some residents are increasingly preoccupied with the hours issue at the expense of patient care.
The surgeons in Maggie's program are not villains; I doubt that they keep the residents in the operating room solely because they need them. It is more likely that the faculty firmly believe that a good surgeon needs to spend time there to be equipped to handle all the complications that may arise in the course of even a "simple" procedure. However, they must also recognize that the RRC determines the rules and they must comply with them. Medical teaching institutions have many venues in which they can work to have the RRC reconsider its position on this policy.
Maggie would have been saved from making this very difficult decision if communication had been better. The program should be cited and Maggie should avail herself the RRC's mechanism of providing anonymous information regarding the program in the future.
- Charap MH. Reducing resident work hours: unproven assumptions and unforeseen outcomes. Ann Intern Med. 2004;140:814-815.
Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz J. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351:1838-1848.