Young doctors exceeding work limits

A large percentage of first-year medical residents exceeded limits on their work hours intended to reduce fatigue-related medical errors, according to a survey conducted by Harvard Medical School researchers. Violations were reported by residents working at 15 of 16 Massachusetts teaching hospitals.

The study found that 84 percent of 1,278 first-year residents surveyed reported at least one violation in the year after the rules were adopted in July 2003 by the national organization that oversees graduate medical education.

The rules limit residents to working 30 consecutive hours and an average of 80 hours a week, and require them to have an average of one day off every seven days.

Researchers found that trainees at 9 in 10 hospitals nationwide violated the rules at least once during the year.

Most of the 16 Massachusetts hospitals in the survey violated all three major components of the new rules.

Compliance improved during the year, researchers said. They have continued to survey the group throughout their four-year residency programs, although they have not yet analyzed more recent data.

But the lead researcher, Dr. Christopher Landrigan of Brigham and Women's Hospital, said a review of second-year responses also found violations.

About 40 percent reported that they had exceeded work hour limits, the study found.

The results are based on an Internet survey from July 2003 through May 2004 and are reported in today's Journal of the American Medical Association. Researchers surveyed first-year residents, also called interns, because they tended to work the longest hours.

The study is part of a growing body of work examining residents' long hours and their impact on patient care and on personal safety. Another study in the same issue found that interns were more likely to stick themselves with needles and cut themselves with sharp instruments while working an extended shift -- more than about 29 hours -- than were interns who worked more than about 6 hours on average.

Many sleep researchers argued that the limits, adopted by the Accreditation Council for Graduate Medical Education, are not strict enough, and that the rules, minimal though they seem, are not enforced as well as they should be.

But defenders of the current rules argue that further reducing work hours could create other problems by reducing the continuity of care; many errors occur when a physician ``hands off" a patient to a new doctor arriving for his or her shift.

Interns take patients' medical histories and perform examinations as well as insert intravenous lines, order medications, and perform simple procedures under supervision from senior residents or attending physicians.

The Harvard researchers' results differ dramatically from findings of the Accreditation Council, which also surveys residents. Dr. David Leach, executive director of the council, said that his group found that 5 percent of all residents reported violating the 80-hour work-week limit during the first year of the new rules. That number fell to 2 percent for the year that ended in June.

He said the council's results are more reliable partly because they survey 85,000 of the country's 100,000 residents. While the Harvard researchers counted a hospital in violation if just one resident reported breaking the rules, Leach said his organization gives residency programs a violation for significant breaks with the rules, including when 15 percent of its residents report they exceeded work limits. This past year, the group cited 8 percent of the country's 8,000 residency programs with a work-hours violation.

Dr. Richard Schwarztstein, vice president for education at Beth Israel Deaconess Medical Center, said the study, which focused on the first year of the limits, is outdated. ``Was everybody on top of the entire thing at that time? No, they weren't," he said. But Dr. Simon Ahtaridis, a resident at Cambridge Hospital and president of the Committee of Interns and Residents, a national union, said the group believes the problem is worse than the council knows. He said residents aren't always comfortable reporting violations, since it will hurt careers if their program loses accreditation.

Liz Kowalczyk can be reached at kowalczyk@globe.com.