On Feb. 13 the Accreditation Council for Graduate Medical Education (ACGME) approved new “resident duty hours language…for insertion into the common program requirements for all core and subspecialty programs by July 1, 2003.” The final regulations are the culmination of the ACGME’s expeditious effort to address the complex issue of resident work hours in the context of medical education. The new requirements are rooted in a report by the ACGME Work Group on Resident Duty Hours and the Learning Environment, which was commissioned in September 2001.
Highlights of ACGME Restrictions
- 80 hours per week, averaged over four weeks, inclusive of all in-house call activities, with up to a 10 percent exception possible.
- One day in seven “off” (one continuous 24-hour period free from all clinical, educational, and administrative activities) averaged over four weeks, inclusive of call.
- 10 hours off between all daily duty periods and after in-house call.
- In-house call every third night, averaged over four weeks.
- 24 consecutive hours on-site, including call, with up to six additional hours for participating in educational activities and maintaining continuity of medical and surgical care.
- Moonlighting is monitored by the program director, and “internal” moonlighting counts toward the 80-hour weekly limit.
ACGME-Approved “Specialty Specific” Language for Neurological Surgery
- Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care. This may include resident participation in the first surgical case of the day.
- No new patients may be accepted after 24 hours of continuous duty. A new patient is defined as any patient for whom the neurological surgery service or department has not previously provided care. The resident should evaluate the patient before participating in surgery.
At its meeting the following June, the ACGME announced preliminary approval of a set of common standards for resident duty hours that would become effective in July 2003. Of these proposed standards, ACGME Executive Director David C. Leach, MD, observed in the August 2002 issue of the ACGME Bulletin, “The change is incremental rather than radical; nonetheless all change affords the opportunity for unintended consequences. Will our attempts to strengthen education and patient safety actually impair the resident’s ability to acquire ‘practical wisdom?’ “
The ACGME approved the proposed standards in September 2002, and accepted public comment until Dec. 31. The final resident duty hours language subsequently announced in February remained very similar to the originally proposed language.
The final language, as well as additional information regarding resident duty hours, is available at https://www.acgme.org. The requirements recognize the importance of “providing residents with a sound academic and clinical education” that is “carefully planned and balanced with concerns for patient safety and resident well-being,” and also that “duty hour assignments must recognize that faculty and residents collectively have responsibility for the safety and welfare of patients.” Six areas under Resident Duty Hours and the Working Environment are addressed: supervision, duty hours, on-call activities, moonlighting, oversight, and duty hours exceptions.
Those voicing support for the ACGME’s plan to address resident work hours have included the Association of American Medical Colleges and the American College of Surgeons. In separate statements on resident work hours issued in June 2002, the AAMC pledged to “work with our members to ensure they continue to closely supervise the learninng environments of residents and remain committed to maintaining adequate rest and time off as high priorities of their graduate medical education programs” and the ACS asserted that “patients have a right to expect a healthy, alert, responsible and responsive physician” and that “it is critical to monitor, modify and optimize the work environment” to achieve quality patient care.
In July 2002 American Medical News reported that the ACGME’s restrictions were supported at the AMA’s June meeting when the AMA passed nearly identical work hour restrictions; the article’s subtitle was prescient: “While some hope this will preempt federal action, others voice concern over the impact on training programs.” In October 2002, the Occupational Safety and Health Administration (OSHA) denied an April 2001 petition by Public Citizen, the Committee of Interns and Residents and the American Medical Student Association that was intended to implement restrictions on resident work hours at the federal level. The petition was denied, partially because of the ACGME’s move to restrict and monitor resident work hours, and also in recognition that the issues involved with resident work hours are more expansive than job safety. However, federal legislation governing resident work hours, proposed but not enacted in 2002, again is pending in Congress.
Manda J. Seaver is staff editor of the Bulletin.