Frequently Asked Questions

 

What are the ACGME work hour regulations?


The basic requirements of the Accreditation Council for Graduate Medical Education (ACGME) Common Duty Hour Standards are outlined below. More detailed information about the Standards can be viewed here in PDF form.

  • An 80-hour limit per week, averaged over 4 weeks
  • A limit on continuous duty of 24 hours plus up to an added 6 hours for transfer of care and didactics; no new patients are permitted to be assigned after 24 hours
  • Adequate rest must be provided between duty periods (this should consist of 10 hour period)
  • 1 day in 7 free from all program responsibilities (“1 day” defined as a continuous 24-hour period), averaged over 4 weeks
  • In-house call no more than every third night, averaged over 4 weeks
  • In-hospital hours during call from home are counted toward the weekly 80-hour limit
  • In-house moonlighting counts toward the weekly 80-hour limit

 

How do I report duty hours violations to the appropriate body?

 
To report work hours violations to the Accreditation Council for Graduate Medical Education (ACGME) contact:
Marsha Miller, ACGME Complaint Officer, at (312) 755-5041 or via email at mmiller@acgme.org

Residents working in New York State can report violations of the Bell Regulations to the Island Peer Review Organization (IPRO) at (518) 426-3300, ext. 103 or at (518) 402-1024

Members of the Committee of Interns and Residents of SEIU Healthcare (CIR) or an independent housestaff union should contact a union delegate or organizer.  CIR’s national office can be reached at 1-800-CIR-8877.

 

What protections do I have if I report a violation to the ACGME?


The ACGME protects the confidentiality of complainants, except when that right is waived or when the specific nature of the complaint makes it impossible to do so. However, as the ACGME notifies hospital administrators and program directors that a resident has filed a complaint, some residents have found it difficult to maintain anonymity, especially in smaller residency programs.

Further questions about confidentiality may be directed to:
Marsha Miller, ACGME Complaint Officer, at (312) 755-5041 or via email at mmiller@acgme.org

 

What is the Accreditation Council for Graduate Medical Education (ACGME)?


The Accreditation Council for Graduate Medical Education (ACGME) is a private, non-profit organization that oversees residency training programs in the US. The ACGME’s board members come from the following medical societies and healthcare industry organizations: The American Board of Medical Specialties, American Hospital Association, American Medical Association, Association of American Medical Colleges, and the Council of Medical Specialty Societies.

The ACGME is responsible for the development and maintenance of curricular standards for US residency programs. To ensure that these standards are met, the ACGME conducts on-site evaluations performed by teams of medical experts known as Residency Review Committees. Normally, all residency programs undergo on-site visits every other year, and hospitals are informed of the date of the visit at least 110 days in advance.

 

Why is the ACGME the wrong institution for setting and enforcing work hour limits?


The first reason lies in the ACGME’s organizational structure. The ACGME is a private, non-profit organization, and its board members are appointed by the independent healthcare industry organizations that comprise its membership, save one federal representative without voting rights, leaving no formal channels for direct public input and accountability. Moreover, there are disturbing conflicts of interest among the healthcare industry member organizations that make up the ACGME. As articulated by The New York Times on its June 14, 2002 editorial page,“Despite the tough talk, the council faces an inherent conflict of interest. Its board is dominated by the trade associations for hospitals, doctors, and medical school, all of which benefit from the cheap labor provided by medical residents.”

Secondly, the ACGME’s enforcement method has proven ineffective. The only sanction that the ACGME wields over residency programs that violate its work hour limits is loss of accreditation. As a result, many residents are understandably reluctant to report work hour violations to the ACGME, not wanting to risk the derailment of their professional careers by the de-accreditation of their residency program.

Additionally, ACGME’s on-site inspections are typically announced to hospital administrators at least 110 days before their scheduled date, and even then only occur once every two years. New York State, by contrast, contracts an independent, peer-review agency to enforce the State’s own resident work hours regulations through annual, unannounced visits to program sites lasting several days and comparing actual hospital records against “official” published schedules. The impotency of the ACGME’s enforcement mechanisms can be seen in the wide discrepancy between the ACGME’s own data on compliance, and data collected by independent Harvard researchers and published in the Journal of the American Medical Association in 2006 (Landrigan, et. al. JAMA, Sept. 6, 2006, 296(9).). 
 

Isn’t working long hours essential for medical training?


Opponents of resident work hour reform often contend that long hours are necessary in medical education so that physicians-in-training have the opportunity to observe the evolution of particular diseases or conditions over time. However, no condition ever develops perfectly concordant to a resident’s schedule, even under the current scheduling. Some conditions pass in minutes, others over the course of hours, days or weeks.

Moreover, even if there are lessons to be learned by physicians-in-training through working excessively long hours, there are serious doubts these lessons are fully retained; scientific studies have shown that long hours of wakefulness impair memory, attentiveness, and concentration – hardly creating an optimal educational scenario (Saxena; George. SLEEP, 2005.; Philibert. SLEEP 2005.; Arnedt, et. al. JAMA, 2005.).

Additionally, scientific evidence has found that patients are at greater risk when attended to by fatigue-impaired doctors. (Barger, et. al. PLoS Med, 2006.).  In surveys, patients themselves have indicated a profound uneasiness about receiving treatment from sleep-deprived doctors (National Sleep Foundation, Sleep in America, 2002). The best interests of the patient should always come before educational considerations.

Other studies have linked extended shifts to a greater risk of self-inflicted needle-sticks and motor vehicle accidents on the post-work commute (Ayas, et. al. JAMA, 2006.; Barger, et. al. NEJM, 2005.). Suffering an injury such as these could seriously derail a resident physician’s medical training.

 

Isn’t a patient safer under the care of only one – albeit tired – physician, rather than facing the additional hand-offs from one physician to another which shorter work hours inevitably cause?


It has long been recognized that errors can occur during the transfer of patient care. Yet a recent randomized control trial published in the New England Journal of Medicine in 2004 showed that the error rate associated with fatigue outweighed the error rate associated with increased hand-offs (Landrigan et al., NEJM, 2004, Oct 28; 351(18):1838-48).

Nonetheless, improving the patient hand-off process is imperative to maximizing patient care. Unfortunately, this objective has received far too little serious attention. There is widespread variability in the way hand-offs are conducted across hospitals, and the process is often denied sufficient attention in physician training programs. As we move to a shorter work hour standard, it is increasingly important that we evaluate how the process of patient hand-offs can be improved.

An excellent resource on how to improve and standardize patient hand-offs is available in our Best Practices section.

 

How has fatigue been legally addressed in other areas related to public safety?


Federal law mandates strict restrictions in other important industries to protect workers and the public from fatigue: Pilots are limited to 8 hours per day, and commercial truckers are limited to 10 hours of driving and 15 hours of duty.

Additionally, in 2003 the State of New Jersey passed a law making driving after 24 hours of continued wakefulness a criminal offence. A number of other states are moving forward towards enacting similar “Driving While Drowsy” laws.
 

What is the recent history of efforts to limit resident work hours in the US?


Public concern about the health and safety effects of excessive resident work hours steadily grew throughout the 1980s and 1990s, as new scientific evidence on fatigue, media coverage of medical errors, and common sense drew people’s worried attention to the medical system. In 1987, New York State formed a commission to examine resident training in the state, following the well publicized death of the daughter of a prominent New York journalist in a Manhattan hospital under the care of intensely overworked resident physicians. Two years later, the commission’s recommendations for stricter resident work hour limits were instituted as New York State Law, becoming known as the “Bell Regulations” after Dr. Bertrand Bell, the commission’s chair.

As state-level efforts to reduce resident work hours were launched elsewhere following the Bell Regulations, physicians and the concerned public began to increasingly call for federal legislation to address the issue. In 2001, a coalition of doctors and healthcare organizations, including the American Medical Student Association and the Committee of Interns and Residents, filed a petition with the Occupational Safety and Health Administration asking for federal oversight of resident work hours as a matter of workplace safety. The same year, Rep. John Conyers (D-MI) introduced congressional legislation limiting work hours, and the bill quickly garnered 71 cosponsors from across party lines.

Facing this wave of public pressure, the ACGME agreed to tighten its notoriously lax and vague resident work hour regulations, in large part to avert the imposition of stronger reform measures. The new ACGME hours regulations took effect July 1, 2003. However, as these current regulations have repeatedly been shown to be inadequate, the need for federal legislation limiting resident work hours remains clear. Rep. Conyers has continued to introduce work hours legislation to each new session of Congress, but the issue has yet to find its way onto the congressional agenda. In the meantime, state-level efforts to regulate work hours persist in Massachusetts and elsewhere.