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Restrictions Get Reality Check
Assessing the Past, Present and Future of Resident
Work Hour Restrictions
PERSPECTIVE
DEBORAH L. BENZIL,MD
Listening to colleagues across the country discuss
their perceptions of the post-July 2003 environment,
I hear hauntingly familiar refrains, the same ones that
echoed throughout New York more than 10 years ago
when the state began to enforce its own resident work
hour restrictions. Because academicians, including
neurosurgeons, learned little from the New York
experience, many will be doomed to repeat the failures
of others, perhaps at the expense of resident satisfaction,
faculty attrition, and sadly, quality of care
for our patients.
Perhaps the most common refrain is that the new
resident work hour restrictions, which were mandated
nationally by the Accreditation Council for Graduate
Medical Education, will debase the profession of
medicine resulting in a “shift-worker mentality”
attended by failure to commit to the best care for our
patients. Anecdotes abound of residents leaving in the
middle of cardiac arrest codes, showing up late for
rounds because they were entitled to their required
time off, and similar behaviors. But these remain
anecdotes, less valid scientifically than case reports,
and the new reality has yet to be assessed.
It is likely that the full impact of the ACGME resident
work hour restrictions will not be understood
for a generation, when the residents training under
this new system gain seniority and assume roles as
program directors and chairs of departments. At this
time, two years into national implementation of the
80-hour resident workweek, a brief look at the history
of this reform and at how the future success or failure
of this change will be assessed may be instructive.
Into the Past
Resident work hour restrictions, arguably medical
education’s most sweeping reform in this century,
evolved following the death of Libby Zion at a New
York Hospital in March 1984. A junior resident
admitted her with fever, chills and dehydration; by the
next morning, she had died. While the exact cause of
her death has never been determined, a New York
grand jury investigation in 1986 found that the death
was related to 36-hour
sleepless resident shifts
and inadequate supervision
by attending
physicians.
Sidney Zion, Libby
Zion’s father and also a
newspaper columnist
and attorney, sued New
York Hospital and the
physicians for malpractice.
More than the
malpractice case, he
began a crusade against the system, targeting the long
resident work hours and poor supervision that he felt
had contributed to his daughter’s wrongful death.
The publicity surrounding this case led the New
York Health Commissioner in 1987 to form an ad hoc
advisory committee chaired by Bertrand Bell, a professor
of medicine at Albert Einstein College of Medicine.
The committee’s strong recommendation to
restrict resident work hours led to New York State
health code legislation enacted July 1, 1989, commonly
known as the 405 Regulations. Sidney Zion,
however, continued to campaign, claiming that many
hospitals were wantonly ignoring the code. In 1998,
stiff hospital penalties were added. Initial violations
could be fined up to $6,000 per violation with followup
violations escalating to $25,000 and then $50,000.
While New York hospitals were struggling with the
405 Regulations, the push to implement national
work hour restrictions began. In 2002 the ACGME
announced its intention to impose national duty
hour regulations effective July 1, 2003.
A Look at the Present
Assessment of the effect of the 80-hour resident
workweek within much of surgery has emphasized
the loss of surgical case volume and the dilution of the
surgical training experience (3,11,13). The two studies
published in this issue of the AANS Bulletin
demonstrate the reduced number of cases in which
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Volume 14, Number 4 • AANS Bulletin 23