Home Government Affairs Newsroom Meetings Publications	Shopping Cart Site Map

ACGME Duty Hours Standard Spark Regulatory Debate

What's in a Name? Philanthropists' Donations Giving New Names to Medical Schools

Proposed New Clinical Exam Draws Cost, Efficacy Concern

Leadership Q & A: A Pioneer Looks Back - And Ahead

Managing Editor
Scott Harris
sharris@aamc.org

Staff Writer
Elissa Fuchs
efuchs@aamc.org

Viewpoint

Resident Duty Hours: Balancing Education and Service

WT Williams MD

Paul Friedmann, M.D., and W.T. Williams, M.D. (pictured above) co-chair the Work Group on Resident Duty Hours and the Learning Environment for the Accreditation Council on Graduate Medical Education (ACGME), and Ingrid Philibert is Director of Field Activities for the ACGME.

The June approval of new resident duty-hour standards represents the realization of an important goal for the ACGME and the academic medical community. The accomplishment is much broader than merely limiting resident hours. At the heart of the effort are assurances that residents have time to learn medicine, that they are rested and able to learn, and that they contribute safely and effectively to patient care.

The fundamental goal is the proper balance between education and patient service. This balance has been debated for decades, and many thought it could be attained without limits on hours. But patient acuity, new technology, and other recent changes in teaching hospitals have increased the demands on residents, and scientific data has accumulated on the effects of sleep deprivation on performance.

These facts cannot be ignored. In this environment, limits on duty hours are vital to promoting high-quality education, safe patient care, and resident well-being. While limiting duty hours is just one element of a larger effort to provide an ideal patient care and learning environment, it is vital to the proper balance between education and service. In developing its recommendations, the Work Group sought the counsel of the academic community. The views expressed illustrate the dual nature of residents as learners and as providers of care. We heard from some who urged against limiting residents' contributions to patient service and who emphasized the difficulty of replacing them given the shortages in many health professions.

Others, who felt that residents are primarily students, argued that a rich learning experience and continuity of care are important considerations, and that limits could detract from both. Still, by far the largest group voiced support for limits on resident hours, with many noting they felt this action was long overdue. A few remembered their own residency, with concerns that they may have placed patients at risk while tired. These powerful and sometimes conflicting voices had in common a profound concern for the quality of resident education. Having heard and carefully evaluated them, the Work Group ultimately was convinced that placing a limit on resident duty hours was the appropriate response to the changing clinical environment and our enhanced information on the science of sleep and fatigue.

At the same time, the Work Group sought to protect didactic education and residents' ability to follow their patients, which is important for learning and appreciating the importance of the quality and continuity of patient care. At a limit of 80 hours per week, there should be sufficient time for residents to both learn and contribute in meaningful ways to the provision of patient care.

Yet the Work Group was sensitive to the fact that the learning needs of specialties differ, and that some may need flexibility to allow residents to participate in educationally valuable activities beyond 80 hours. Programs have the option, with approval from the sponsoring institution and the Residency Review Committee, to extend duty hours up to 10 percent beyond the 80-hour weekly limit. A sound educational rationale is required.

We realize that in many programs, the new standards will signify fewer duty hours for residents, and will necessitate changes. To promote adherence, the ACGME has strengthened institutions' responsibility for oversight and monitoring of duty-hour practices and is committed to consistent, unwavering enforce ment of the standards.

An additional role for the ACGME and other organizations in the academic community will involve serving as conduits for information on sleep deprivation and appropriate countermeasures, and as clearinghouses for best practices in meeting service demands with fewer residents.

Ultimately, although the academic community can assist, the success of the effort will rest with residency programs and teaching institutions. It will depend almost entirely on their willingness to make changes to their complex systems of care, changes necessary to foster the proper balance among three imperatives - education, safe patient care, and resident well-being.