AMA House of Delegates

Students oppose the five-hour nap rule for residents, says Michael Best of the Medical Student Section.

AMA meeting: Nap time mandate for on-call residents rejected

Delegates support tracking studies of how resident fatigue affects patient safety, but they say medicine -- not politicians -- should devise duty-hour rules.

By — Posted Nov. 23, 2009

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A mandated five-hour nap time for medical residents on call could worsen patient safety by disrupting the continuity of care, the AMA House of Delegates said in a report adopted at its Interim Meeting.

The AMA will urge the Accreditation Council for Graduate Medical Education to reject a protected sleep period proposed by an Institute of Medicine report published in December 2008. That and other changes proposed by the IOM come with an estimated $1.5 billion price tag and would be difficult to implement, according to AMA Council on Science and Public Health recommendations the house adopted.

"There is a growing body of information exploring sleep deprivation and care and safety issues, particularly in residents, but there is a belief that it's not complete enough to support the restrictive hours that the Institute of Medicine had recommended," said AMA Board of Trustees member Edward L. Langston, MD, a Lafayette, Ind., family physician who in the past served on the ACGME board of directors.

Delegates also said the AMA should work to keep control of duty-hour decisions in the hands of the ACGME and free from the intervention of politicians, Joint Commission or Centers for Medicare & Medicaid Services.

"Addressing the rules and regulations around the training of physicians in various disciplines should reside with the profession," Dr. Langston said.

Surgeons have been especially outspoken about the effect of duty-hour rules on training.

"There really should not be further tinkering with work-hour restrictions," said AMA Trustee Peter W. Carmel, MD, a Newark, N.J., pediatric neurosurgeon, in reference committee testimony. "Our colleagues in Europe are suffering with the fact that they have such restrictions on work hours that they cannot train neurosurgeons the way they should be trained. ... They turn out neurosurgeons who cannot pass the board of the American Board of Neurological Surgery."

Medical students also backed the AMA's stance on required sleep. "We strongly oppose the five-hour nap time rule until such a time as there are clear data to suggest the benefits of that policy," said Michael Best, a regional medical student delegate who spoke on behalf of the Medical Student Section.

The AMA will continue to study the evidence on the effect of work-hour restrictions on physician training and patient care. The ACGME is reviewing its regulations and could propose new rules in February 2010.

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Meeting notes: Other actions

Issue: Courts may judge physicians in medical liability cases by developing new standards based on clinical and practice guidelines, risk management, utilization review and other cost-containment efforts -- especially if congressional health reform legislation does not contain language counterbalancing such arguments. Such federal legislation also could preempt effective state liability reforms.

Proposed action: Advocate for legislative language protecting both existing effective state medical liability reform programs and states' ability to enact such reforms. Lobby for legislation to establish a noneconomic damage cap of $250,000 or lower. [Adopted]

Issue: The potential savings to the health system from national medical liability reform legislation is not known.

Proposed action: Contract with an independent, third-party organization to estimate the impact national tort reform legislation would have on the system, with an update every 10 years. [Adopted]

Issue: The Medicare Modernization Act of 2003 authorized federal payments to states for emergency care for undocumented immigrants. But this support will end in May 2010.

Proposed action: Support congressional legislation to extend federal support for such emergency care. [Adopted]

Issue: Physicians who issue only paper prescriptions for patients in Medicare Part D will face pay cuts starting in 2012, but the U.S. Drug Enforcement Administration still requires prescriptions for many controlled substances to be written on paper. The DEA issued a proposed rule in June 2008 that would establish standards for electronic ordering of such drugs, but the rule has not been finalized.

Proposed action: Report the AMA's progress in advocating for electronic prescribing of controlled substances and on DEA efforts to issue reasonable requirements for electronic prescribers. [Adopted]

Issue: Forty state medical boards ask about physicians' history of mental illness, potentially discouraging doctors from seeking appropriate treatment for psychiatric disorders.

Proposed action: Work with the Federation of State Medical Boards and others to develop less discriminatory application language that is consistent with boards' mission to protect public health. [Adopted]

Issue: Cosmetics makers are not required to disclose the ingredients in their products, and there is no legally required testing to make sure they are safe.

Proposed action: Support pending legislation that would require ingredient disclosure, adverse-event reporting and good manufacturing practices. [Referred]

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