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Study Finds Nationwide Non-Compliance in First Year Following Implementation of Work-Hour Limits for Medical Interns

September 5, 2006



Harvard Medical School Press Release. For more information, please contact: Jessica Podlaski, 617-534-1603, jpodlaski@partners.org or Leah Gourley, 617-432-0442, public_affairs@hms.harvard.edu.

Nearly 84% of interns reported work hours in violation of the standards during one or more months

Boston  – Researchers from the Divisions of Sleep Medicine at Harvard Medical School (HMS) and Brigham and Women’s Hospital (BWH) found that interns from across the country commonly reported non-compliance with work-hour limits in the first year following implementation of restrictions set by the Accreditation Council for Graduate Medical Education (ACGME).

Additionally, interns’ average work duration showed only a minor decrease and their average sleep time only slightly increased. These findings are particularly important because past research has confirmed that sleep deprivation is associated with an increased risk of serious medical errors and car accidents among interns. The study appears in the September 6, 2006 issue of the Journal of the American Medical Association. 

“While we were not surprised to see some interns exceeding the ACGME’s work-hour limits, it was a shock to find that the large majority of interns violated the limits,” said lead author Christopher Landrigan, MD, MPH, HMS assistant professor of pediatrics and of medicine and director of the Sleep and Patient Safety Program at BWH. “The dangers of excessive work hours are well established. We hoped this first national effort to reduce work hours would have been a small step toward safer patient care; unfortunately, even the permissive limits of the ACGME appear to have been largely ignored.”

Senior author Charles Czeisler, MD, PhD, director of the Divisions of Sleep Medicine at BWH and HMS and the Frank Baldino, Jr., PhD professor of sleep medicine, added, “this raises serious concerns as to how meaningful reform of physician work hours can be implemented.”

In 2003, the ACGME implemented work-hour limits for all physicians-in-training in the United States. Under these guidelines, interns are limited to work a maximum of 30 hours in a row and no more than 80 weekly hours, averaged over four weeks. Additionally, interns are supposed to be off from work one in seven days.

In this national web-based study completed through the Harvard Work Hours, Health and Safety (HWHHS) program, 4,015 interns completed monthly surveys to assess their work and sleep hours pre-implementation (July 2002 to May 2003) and post-implementation (July 2003 to May 2004) of ACGME guidelines. In total, interns completed 29,447 monthly surveys, representing residency programs from around the country and across specialties.

The researchers found that in the first year following implementation of the ACGME duty-hour standards, interns commonly reported non-compliance with these limits. Specifically:

  • 83.6 percent of interns reported work hours in violation of the standards during one or more months.
  • Working shifts greater than 30 consecutive hours were reported by 67.4 percent.
  • Averaged over four weeks, 43 percent reported working more than 80 hours weekly and 43.7 percent reported not having one day in seven off from work.
  • Violations were reported during 44 percent of all months assessed (including months with vacations and clinic rotations), and during 61.5 percent of months during which interns worked exclusively in hospitals.
  • 29 percent of reported work weeks were greater than 80 hours per week, 12.1 percent were equal to or greater than 90 hours and 3.9 percent were equal to or greater than 100 hours.

The researchers also found that compared to pre-implementation of guidelines, reported mean work duration decreased only 5.8 percent from 70.7 hours to 66.6 hours. Reported mean sleep duration showed only a 22-minute (6.1%) increase from 5.91 hours to 6.27 hours a night and actually showed a 4.5 percent decrease in sleep duration during on-call, overnight hospital shifts.

These findings challenge data reported by the ACGME, which found that only 3 percent of residents and 5 percent of residency programs were non-compliant with the rules. Landrigan explained it is possible that under-reporting to the ACGME occurred because residency programs that report violations to the ACGME are at risk of being shut down.

“[Our] data demonstrate that academic medical centers have not complied with even the very modest restrictions that the medical profession attempted to self-impose on physician work hours,” said Czeisler.

Landrigan added, “If we are to begin addressing the epidemic of medical errors in this country…we must begin by establishing and enforcing safe work hour limits for our doctors.”

Co-authors of the study include Laura Barger, PhD, Brian Cade, MS, and Najib Ayas, MD, MPH. 

The National Institute for Occupational Safety and Health within the United States Center for Disease Control, the Agency for Healthcare Research and Quality, and BWH supported the research.

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Related Link: Publication details

Related Press Release: Extended Work Shifts Put Medical Interns At Risk Nationwide

Harvard Medical School
http://hms.harvard.edu/
Harvard Medical School has more than 7,000 full-time faculty working in eight academic departments based at the School's Boston quadrangle or in one of 47 academic departments at 18 Harvard teaching hospitals and research institutes. Those Harvard hospitals and research institutions include Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Cambridge Health Alliance, The CBR Institute for Biomedical Research, Children's Hospital Boston, Dana-Farber Cancer Institute, Forsyth Institute, Harvard Pilgrim Health Care, Joslin Diabetes Center, Judge Baker Children's Center, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, Massachusetts Mental Health Center, McLean Hospital, Mount Auburn Hospital, Schepens Eye Research Institute, Spaulding Rehabilitation Hospital, and VA Boston Healthcare System.

Brigham and Women’s Hospital
BWH is a 747-bed nonprofit teaching affiliate of Harvard Medical School and a founding member of Partners HealthCare System, an integrated health care delivery network. BWH is committed to excellence in patient care with expertise in virtually every specialty of medicine and surgery. The BWH medical preeminence dates back to 1832 and today that rich history in clinical care is coupled with its national leadership in quality improvement and patient safety initiatives, dedication to educating and training health care professionals, and strength in biomedical research. With $370M in funding and more than 500 research scientists, BWH is an acclaimed leader in clinical, basic and epidemiological investigation - including the landmark Nurses Health Study, Physicians Health Studies, and the Women's Health Initiative. For more information visit www.brighamandwomens.org.

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