The Problem: You've seen them on Scrubs, ER and Grey's Anatomy -- deeply fatigued interns and residents. But truth is stranger than fiction. More than 100,000 resident physicians in teaching hospitals across the country are routinely scheduled to work shifts of 24-30 consecutive hours, with little or no sleep. They work in operating rooms and ERs, on the wards and in the clinics. And when they are finished working, they get behind the wheel of a car and drive home. After that, they are likely to be back in the hospital for two days of "short" 8 or 12-hour shifts. Then it is another up-to 30-hour "on-call" shift. This brutal schedule can continue for years.

The Evidence: There is substantial scientific evidence that these marathon work hours are linked to a significant increase in attentional failures, performance deficits and medical errors - and to increased car accidents that harm residents and the drivers and passengers they crash into. In fact, resident fatigue was the subject of a gold-standard, randomized controlled trial proving the efficacy of reduced work hours in reducing medical errors. The prestigious Institute of Medicine (IOM) has also concluded that there should be a further reduction in work hours. Other industries responsible for public safety (e.g., the transportation and nuclear power industries) have been subject to federal regulations that limit the number of hours their employees can work for decades. Why not in medicine, where the stakes are at least as high or higher?

When the Industry Controls Hours: The ACGME (Accreditation Council on Graduate Medical Education) oversees the training of physicians in the U.S. It is a private entity comprised of four physician organizations and the American Hospital Association. In 2003, facing the threat of both federal regulation and legislation that would have restricted resident physician hours, the ACGME reluctantly established the first voluntary, cross-specialty hours limits for residents.

But the limits they set are still unsafe. Eighty-hour work weeks averaged over 4 weeks allow residents to work well over 100 hours in some weeks. "On-call" shifts of 24-30 consecutive hours can (and are) scheduled as often as ten times a month. Residents are allowed one day off a week, but even that can be averaged over 4 weeks. And enforcement of these limits depends to a large extent on individual resident physicians blowing the whistle on violators. There is little incentive to do so, however, because the only penalty available to the ACGME is putting the program on probation or revoking its accreditation. Reporting a violation places a resident's chances of graduating from an accredited program at risk, a gamble that most would not want to take. A 2006 study published in the Journal of the American Medical Association supports this notion. It found that the majority of interns have violated one or more of the standards since they were put in place in 2003.

Congress takes an interest: The ACGME is well aware of the evidence from many industries linking long work shifts to preventable accidents and errors. But the culture of medicine ("I worked these hours, so you should, too") is strong, and resident physicians provide cheap labor for the nation's teaching hospitals.

In 2007, members of the House of Representatives Energy and Commerce Committee asked the federal Agency for Healthcare Research and Quality (AHRQ) to investigate resident work hours and patient safety. AHRQ turned to the IOM. A handful of organizations (Public Citizen, Consumers Union, the Committee of Interns and Residents/SEIU Healthcare, the American Medical Student Association), as well as two internationally renowned sleep scientists, provided testimony to the Institute of Medicine committee, pointing to the existing scientific evidence of harm to patients and residents and stressing the need to set lower, safer hours limits and to enforce them.

New IOM report released: On December 2, 2008, the IOM released its report, Resident Duty Hours: Enhancing Sleep, Supervision and Safety. The report summarizes the robust evidence base linking fatigue with decreased performance and higher medical error rates. It asserts that "strong and prompt action" should be taken to reduce residents' work hours and provide more time for adequate rest, thereby improving patient safety. It further recommends stronger enforcement of work-hour rules. This report is the most comprehensive, up-to-date report on this topic ever prepared.

ACGME Duty Hours Joint Task Force formed: In response to the IOM report, the ACGME created a task force charged with making recommendations on the current work hours regulations. In June 2009, the Duty Hours Congress was held (by invitation only) in Chicago. More than 140 medical organizations weighed in, with only two organizations, the Committee of Interns and Residents and the American Medical Student Association, in support of the IOM recommendations! In an "Open Letter to the GME Community" (10/28/09), ACGME Executive Director Dr. Thomas J. Nasca explained that the task force had commissioned three reviews of the literature (apparently the 428-page IOM report was not thorough enough) and was soliciting "additional perspectives." The lack of transparency and public input into these deliberations is troubling to say the least.

The ACGME intends to produce draft recommendations for consideration by the ACGME Board of Trustees in February of 2010.

Let the ACGME know that you expect this Task Force to objectively review the scientific evidence and act in the public's interest.

For more information:

• Learn more about the Institute of Medicine's recommendations on resident duty hours
• For an extensive review of the evidence linking long hours to medical errors, visit the Harvard Work Hours Health and Safety Web site.
• For resident physician and medical student perspectives on long work hours visit the Committee of Interns and Residents.