167that the requirements for additional personnel and ancillary services in New York
State would require hiring over 5000 full-time personnel, which would cost state in
excess of $358 million dollars [ 20 ].
Changes in Duty-Hour Restrictions in the US Training Programs
The changes proposed by the Bell Commission and its application by the New York
State Board of Health catalyzed action by many groups to address the issue of resi-
dent work hours across the United States [ 5 ]. In April 2001, the Occupational Safety
and Health Administration (OSHA) was petitioned by multiple groups including
Public Citizen, the American Medical Student Association, The Committee of
Interns and Residents, and Drs. Bell and Strohl to create national regulations regard-
ing duty hours for all medical residents and fellows in the United States. Legislation
was also introduced in the House of Representative and in the Senate to make into
law the regulations that were being requested from OSHA. In late October of 2002,
the Occupational Safety and Health Administration denied this petition stating that,
“other knowledgeable groups are taking action on this problem.” It was clear that
government regulation of resident work hours was impending. Impressed to perhaps
exert control over the future of its own trainees, the American Association Medical
Colleges recommended an 80-hour workweek and published its policy shortly
thereafter. Similarly, the House of Delegates of the American Medical Association
also recommended an 80-hour workweek averaged over 2 weeks for US medical
residents and fellows, with a possible increase of up to 5% for some select pro-
grams. Finally, in February 2003, the Accreditation Council for Graduate Medical
Education (ACGME) whose mandate, “sets standards for US graduate medical edu-
cation (residency and fellowship) programs and the institutions that sponsors them,
and renders accreditation decisions based on compliance with these standards,”
approved its final version of its recommendations [ 21 ]. The work standards took
effect on July 1, 2003 and applied to all programs in all specialties. It set a limit of
an 80-hour workweek averaged over a 4-week period, every third night on call as a
maximum, and 1 day out of each 7 free from patient care responsibilities. Programs
also are required to give residents a minimum of 10-hour rest between duty periods.
Additionally, all “on call” activities were limited 24 hour plus an additional 6 h of
time for transfer of care, continuity of care, education, and didactic activities. It was
prohibited for new patient interactions to occur during this time. Up to 10% vari-
ance in specific cases was allowed for sound educational reasons. The ACGME
guidelines for 2003 are found in Table 9.1.
In response to duty-hour regulations, studies documented both a positive and
negative impact on the surgical residency experience. In a survey of general surgery
programs in New York State, Whang et al. examined resident attitudes to the changes
mandated by the “405 Regulations” (i.e., the Bell Commission recommendations)
[ 22 ]. The majority of residents felt “more rested” and had “a better quality of life
outside of the hospital” after implementing the regulations. Many residents felt that
there was a decrease in the quality of their work, the quality of their training, and the
9 Resident Duty Hours in Surgical Education