WASHINGTON – Dr. Donald Abrams can remember the bad old days of his medical residency, when working 36 hours straight was the norm. He remembers nurses congratulating him on saving the life of a patient he couldn’t remember operating on.
“In past years the amount of hours a resident was supposed to work was ungodly,” said Abrams, the director of graduate medical education for Sinai Hospital in Baltimore.
Things have improved since then: Where surgical residents in Abrams’ day typically worked 120 hours a week, today they average 90 to 100 hours a week, he said.
Hospital officials will have to reduce the numbers even further this summer under new rules that will limit the number of hours residents can work in a given week, limit the amount of time they can spend on-call and set a minimum amount of downtime for residents.
The rules were created by the Accreditation Council for Graduate Medical Education and hospitals that do not comply by July or face probation or loss of accreditation by the council.
In Maryland, there are more than 1,700 residents in a variety of fields spread between 17 hospitals. Officials said they expect all of those hospitals will comply with the new rules — even though they worry that the rules will increase costs while slowing residents’ progress.
“What we need to be sure of as we make these changes is that there is proper time for patient-care training,” said Dr. Donald Rorison, the vice president of medical affairs at the University of Maryland Medical Center. “You’re really balancing resident well-being and patient safety.”
Abrams said that residents could suffer a small loss in proficiency because of reduced practice time. Some programs have even proposed lengthening the residency period to account for this, he said.
But the biggest impact would be on continuity of patient care, Abrams said. Some patients might wake-up after surgery to a different doctor than the one that operated on them.
Rorison also said it will probably cost his medical center millions to hire the extra residents and ancillary staff to make up for the hours that will be lost as a result of the new rules.
Dr. William Thomas, the vice president for medical affairs at MedStar, agreed that hospitals in his system will have to hire a few staff members and streamline some of operations. But he did not think costs would reach into the millions.
“Yes it’s difficult to reorganize in some cases, but it’s the right thing to do,” Thomas said.
Under the rules, residents and fellows in all accredited training programs in the country will be restricted to working 80 hours per week, averaged over four weeks. That nummber could be increased by 10 percent under some circumstances, according to the council’s web site.
Residents will also be guaranteed one day off out of every seven, also averaged over four weeks, and will get 10 hours off between duty periods and after in-house on-call.
Residents will limited to 24 consecutive hours on-call, although they could work an additional six hours to hand off patients or attend education activities.
Makeba Williams, the legislative affairs director for the American Medical Student Association, said that while the accreditation council’s rules are a good start, they need to go further because hospitals have been neglecting residents’ health for too long.
“We are encouraged that the ACGME has addressed this issue, but we are still pursuing independent legislation,” Williams said.
She said that the association believes that letting hospitals average the hours worked in a four-week span still allows dangerous working practices to continue. Williams also said that she does not have confidence in the ability of hospitals to effectively regulate themselves.
“The medical community has not done an adequate job in the past of self- regulating,” she said.
New York created an 80-hour workweek rule in 1989, for example, and a recent report by the New York Health Department showed that roughly 64 percent of hospitals in the state are not complying with some portion of the workweek guidelines.
But Williams said there have been very few problems otherwise with tightened resident work rules in New York, where she said 15-20 percent of all residents get their training.
Maryland hospital officials agree that the New York experience shows that the new rules can work, even if it will take some tinkering on their parts.
“Until we really live with it and see what the implications are it’s hard to say,” what the impact will be Rorison said.
“Certainly the guidelines are reasonable, the challenge is going to be ensuring the quality of education,” he said.