Residency work hour restrictions are again at the forefront of discussion among emergency medicine leaders. It has been 5 years since the Accreditation Council for Graduate Medical Education (ACGME) has updated its accreditation requirements for resident duty hours (RDH). This year, the ACGME is undertaking a comprehensive review of their controversial 2011 duty hour requirement enactment. After gathering written testimony from upwards of 50 organizations and reviewing relevant literature, the group met in March for the ACGME Congress on the Resident Learning and Work Environment.
In-person testimony from a wide range of specialties showed common concerns, including the need for increased flexibility with the current duty hour standards and less stringent monitoring. The group looked to emergency medicine in particular for insight on how to manage 24/7 attending-level supervision while avoiding a clock-punching mentality.
After the March meeting, the ACGME task force aimed to develop recommendations for public comment. Based on that feedback, the new duty hours proposal then will be revised by the task force before being sent to the ACGME board for approval. Implementation of revised duty hour restrictions is expected during the coming year.
History of Duty Hours
In the past, restrictions on hours worked by residents virtually did not exist. Assuredly, every current resident regardless of specialty has heard stories from their attendings about the days when residents were not “coddled,” when residents would stay in the hospital for days at a time without seeing the light of day or their families or friends. The first regulations governing RDH were instituted in New York State in 1989 following the death of Libby Zion, who died at the age of 18 under the care of what her family and policymakers believed were overworked intern physicians. The ACGME's more restrictive 2011 RDH rules were developed in the shadow of the landmark Institute of Medicine (IOM) report entitled Resident Duty Hours: Enhancing Sleep, Supervision, and Safety, published in 2009.1 The IOM report called for more stringent resident duty hours than had been in place since 2003. In 2011, the ACGME responded by imposing the current work hour restrictions, including a 16-hour duty limit for PGY-1 residents, a maximum 28-hour shift length for PGY-2 and PGY-3 residents, and an 80-hour average workweek. By focusing on fatigue as the cause of medical errors, these duty hour requirements led to programs scrambling for patient care coverage and instituting shift schedules, dramatically increasing the number of handoffs.2 This also drastically increased administrative burden for programs and residents alike, and created scheduling gaps that prompted hospitals to hire additional advanced practice providers at significant cost. Paradoxically, resident surveys show that duty hour restrictions have failed to reduce resident burnout and fatigue.3
Future of Duty Hours
This year, the RDH standard will be revised, for the first time, with patient outcome-driven evidence, including two very large randomized controlled trials. The FIRST trial (Flexibility in Duty Hour Requirement for Surgical Trainees) was published online by the New England Journal of Medicine on February 2, 2016.4 In this trial, every general surgery residency program in the United States (except those in New York state) was randomized to one of two groups: either following the 2011 RDH requirements or following a more flexible format in which the 80-hour average work week rule was enforced, but without restrictions on the length of any single shift. After one academic year, there were no measurable differences in patient outcomes (30-day indicators of morbidity or mortality) between the two groups. Residents in the flexible duty hours group felt less frustrated and had fewer concerns for patient safety, although they perceived that their RDH had a more negative impact on rest and time spent with family and friends. The other large trial is the iCOMPARE trial, focusing on internal medicine residencies. This trial is scheduled to conclude in June 2016.
The ACGME invited many medical specialty societies, including ACEP, to comment on the current RDH standards and to provide constructive input on the development of the newest version. In response, ACEP convened a working group of 12 experts in medical education, each with extensive experience in graduate medical education in emergency medicine. ACEP also collaborated with the Council of Emergency Medicine Residency Directors (CORD-EM) to conduct a robust survey of EM educators to gain a deeper understanding of the broader specialty perceptions of the impact of current ACGME duty hours on patient care, resident wellness, educational experience, and residency and hospital costs.
More than 150 CORD-affiliated EM program directors and educational leaders responded to the survey. The general sentiment from those surveyed is that the current duty hour restrictions are good for resident work-life balance, but may be negatively impacting resident education. Respondents perceived that the current restrictions lead to residents being more concerned about completing their shifts on time than following through on patient care and being invested in patients. RDH standards lead to more patient hand-offs (particularly the 16-hour rule for interns), thus raising concerns for more medical errors and less continuity of patient care. More handoffs among EM residents and admitting residents may lead to longer time to staffing and decision-making, prolonged time to admission/discharge, and extended ED boarding. Respondents also identified a concern about consultant competency, as these residents now have less overall patient exposure by the time they graduate. All of this has the perceived potential to cause worse patient outcomes. On a departmental and programmatic level, the current RDH standards also have a significant impact. As mentioned above, they are perceived to increase faculty workload and create a significant administrative burden for residency programs, and result in an increased need for advanced practice providers to fill schedule gaps.
Taking these comments into consideration, the ACEP medical education expert working group was able to create a statement expressing the College's position on the current state of RDH and its recommendations. In brief, ACEP believes that the RDH should promote a supportive educational environment, maintain resident well-being, and protect patients. The RDH should strike a careful balance between the wellness of resident physicians and an adequate duration of time spent with patients to generate sufficient experience for mastery of clinical expertise. ACEP was very concerned about the increased frequency of patient handoffs generated by the 2011 RDH requirements. Furthermore, ACEP proposes the need for individual specialties to develop their own specific requirements that fit their practice best. Emergency medicine has always upheld a more stringent duration of RDH in a week (60 hrs vs. 80 hrs) than other specialties. ACEP's formal recommendations to the ACGME are as follows:
- ACEP supports efforts to study the effects of relaxing duty hours monitoring and reporting.
- ACEP recommends that all trainees not on Emergency Medicine rotations should be limited to 24-hour continuous scheduled duty hours, regardless of their level of training.
- ACEP supports a minimum 10-hour rest interval between duty hour periods for shifts twelve hours or less, and a 14-hour rest period after shifts exceeding 24 hours.
- Rotating residents should be subject to the duty hour standards of the host residency program (i.e. EM residents on a surgery rotation would follow the standards of the Surgery Residency Review Committee and vice-versa).
For More Information
The testimony and position statement ACEP provided to the ACGME Congress can be found here. Stay tuned to emra.org to get a link to the new accreditation program requirements, which are expected to be posted for a 45-day public comment period in the spring.Â This will provide an important opportunity for residents to offer direct feedback on their experience with the RDH.
The future of medical training will depend on adequate input from educators, faculty, residents, and, most importantly, patients. With sufficient foresight, the 2016 version of the ACGME RDH requirements will be the most scientifically-validated version to date.
- IOM (Institute of Medicine). Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. The National Academies Press. Washington DC, 2009.
- Desai SV, et al. Effect of the 2011 vs 2003 Duty Hour Regulation-Complaint Models on Sleep Duration, Trainee Education, and Continuity of Patient Care. JAMA Intern Med. 2013;173(8):649-655.
- Ripp JA, Bellini L, Fallar R, Bazari H, Katz JT, Korenstein D. The impact of duty hours restrictions on job burnout in internal medicine residents: a three-institution comparison study. Acad Med. 2015;90(4):494-499.
- Bilimoria KY, Chung JW, Hedges LV, et al. National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training. N Engl J Med.2016;374:713-727.