In March 1987, the New York State Commissioner of Health appointed an Ad Hoc Advisory Committee on Emergency Services to analyze the grand jury’s findings. The committee, chaired by Dr. Bertand Bell, reviewed the grand jury’s report and issued several recommendations to the New York State Department of Health, including that residents should not work more than 80 hours per week, more than 24 consecutive hours, or more than 6 days without at least one 24-hour period off duty (Holzman and Barnett, 2000; Kwan and Levy, 2002). Rest periods of at least 8 hours between shifts were also mandated (Holzman and Barnett, 2000). ER residents and attending physicians were limited to 12-hour shifts (Kwan and Levy, 2002). The committee’s recommendations were then incorporated into the New York State Code in 1989. Although the New York Hospital Association immediately filed suit contending that the regulations were arbitrary, had been improperly adopted, and failed to provide adequate reimbursement for the increased costs of their implementation,6 its appeal to the State Supreme Court failed (Patton et al., 2001).
Also in 1989, the ACGME amended its regulations to require accredited internal medicine residency programs to limit the hours worked by residents. Internal medicine residents could spend no more than 80 hours per week providing patient care, could be on call no more than every third night, and on average would have to have the opportunity to spend at least 1 of every 7 days free of patient care duties (Green, 1995). Today there are 26 sets of different guidelines, each developed by a different Residency Review Committee. Weekly work hour limitations range from “whatever is considered ‘appropriate’ by residency directors” (general surgery) to 72 hours (emergency medicine) (Gurjala et al., 2001; Kwan and Levy, 2002). Not only are the guidelines inconsistent across the various specialties, but they are also voluntary, not mandatory.
Neither the Bell Regulations in New York nor the ACGME guidelines have been effective in curtailing the hours worked by resident physicians (Gurjala et al., 2001; Kwan and Levy, 2002). Fully 92 percent of New York hospitals were not complying with the Bell Regulations during 1991–1992, a fact known by the New York State Department of Health (Patton et al., 2001). In a survey conducted almost 10 years after the Bell Regulations were enacted, residents in all New York teaching hospitals reported working an average of 95 hours per week (Anonymous, 1998). In 1998, a surprise investigation conducted by the New York State Department of Health found all 12 hospitals visited to be violating resident work hour limits. Over one-third of the residents (38 percent) had worked in excess of 24 consecutive hours, 37 percent were working more than 85 hours per week,