Limiting resident work hours. (Guest Editorial).

I strongly believe in the limits on resident work hours set forth in the new guidelines from the Accreditation Council for Graduate Medical Education, which take effect this July, but I strongly oppose micromanagement of resident work hours.

The new ACGME guidelines limit resident work weeks to 80 hours of in-house activity averaged over 4 weeks, and set limits on shifts, call, and call frequency The guidelines are well intended, but absolute enforcement of the rules will create hardships for training programs and a shift in values among residents.

Unless we are willing to rethink the whole model of training, we'll harm our training programs by applying the new rules too strictly.

I'm concerned based on my firsthand experience with strict work-hour regulations here in New York State. In the 1980s, the state set limits on the number of hours that house staff could work. The ACGME guidelines contain some key elements of New York's regulations.

In 1999, New York State shifted from substantial compliance to absolute compliance with the regulations, resulting in catastrophic logistic problems for the state's medical residency programs. Nor allowing necessary flexibility of patient care has created nightmarish systems in the hospitals.

Patient safety is the key rationale for limiting resident work hours, and although it's probably a valid rationale, we're a long way from proving it. Many studies have shown that fatigue leads to cognitive impairment when people are tested in a formal setting, but no studies have shown an increase in patient errors in actual clinical settings. At Mount Sinai School of Medicine, we recently tracked resident order entry errors and found no correlation with the number of hours they had worked (up to 28 hours). In fact, the peak error rate occurred in late morning, not when residents would typically be tired.

Still, I'm convinced that the educational environment does improve when work hours are restricted. People are not ready to learn when they're so tired that they fall asleep reading a patient's chart. (I once fell asleep standing in an elevator when I was a resident! I'm amazed that my postural tone held. The person who found me standing there was very frightened.)