Sounding Board
The New Recommendations on Duty Hours from the ACGME Task Force
N Engl J Med 2010; 363:e3July 8, 2010
- Article
In July 2003 the Accreditation Council for Graduate Medical Education (ACGME) enacted resident duty-hour standards for all accredited programs that sought to integrate limits on resident hours within the larger set of ACGME standards. The aim of these standards was to promote high-quality learning and safe care in teaching institutions.1 When the standards were established, the ACGME promised the profession that it would revisit them in 5 years.
The educational community and the public have identified three elements of the 2003 standards as particularly problematic. First, the duty-hour limits may have created or exacerbated the adoption of a “shift mentality” during residency. This attitude may conflict with physicians' moral and professional responsibility to their patients and may leave residents unfamiliar with and unprepared for the hours and professional obligations of practicing physicians. Second, duty hours remained the primary focus for programs and institutions; larger changes in the learning environment that were envisioned when the duty-hour standards were instituted in 2003 never materialized.2 Changes discussed extensively in the formulation of the current requirements included enhancing supervision and faculty oversight of care, improving handover practices, engaging in further study of the relationship between sleep and performance, and increasing the attention paid to safety as a systems issue. Third, the current limit on continuous duty is the subject of intensive debate, with lingering concerns that it may leave residents susceptible to the effects of acute sleep loss. Residents in surgical and inpatient-intensive medical specialties also have difficulty complying with this standard, which places them in the ethical quandary of choosing between leaving patients in order to comply with “the rules” or violating the standard by remaining with a sick patient when they believe it is their professional responsibility.3 Of added concern are reports suggesting that the 2003 limits did not increase residents' hours of sleep4 or reduce fatigue5,6 and that the added time created under the new standards is not being used by residents for reading and study. Most important, studies using national data samples failed to show that the duty-hour limits had a positive effect on the quality and safety of inpatient care.7-9
Coincident with the 5-year anniversary of the standards, the Institute of Medicine (IOM) released the report Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. 10 It discussed attributes of the educational program beyond resident hours that promote patient safety in teaching hospitals, including appropriate supervision and transfers of care and a culture of safety in educational settings. The components that received the most attention, however, related to further modifications of the ACGME standards, the significant associated costs, and criticism of the effectiveness of the ACGME's enforcement of its duty-hour standards.
In consultation with its Council of Review Committee Chairs, the ACGME commissioned a 16-member task force to review relevant research, hear testimony, and draft new standards. The group received written position statements from more than 100 medical organizations, heard personal testimony, and held discussions with members of the IOM committee, patient advocates, sleep physiologists, experts on patient safety and quality of care, educators, and international medical educators with experience in systems with greater restrictions on resident hours. The testimony echoed many of the concerns about the limitations of the standards that the ACGME had identified. A particular concern was that the same standards were being applied to different specialties and residents at different levels of training and expertise. Perhaps the most challenging aspect of the work done by the task force entailed reconciling recommendations from the IOM committee to further restrict resident hours — particularly the continuous duty period — with the request from the medical education community to incorporate more flexibility for different specialties and levels of training.
Although much of the debate has focused on establishing appropriate limits on resident hours, the task force recognized that ensuring patient safety and providing an excellent teaching environment entail more than setting these limits. Paramount is an environment characterized by supervision customized to residents' level of competence, faculty modeling of fitness for duty, and the provision of high-quality care in a team setting and an institutional culture of safety and reliability in which redundant systems prevent errors from reaching the patient. A pivotal attribute of this culture is the meaningful involvement of residents in institutional efforts to enhance the safety and quality of care.
The IOM report noted that sleep loss, inexperience, workload intensity, inadequate supervision, poor handover practices, and systemic factors contribute to the errors made by residents (and other health professionals), yet the relative proportion of errors attributable to each factor is not known.10 Studies of closed malpractice claims have implicated lack of supervision, handover practices, and general communications issues as the major factors contributing to errors in teaching settings.11 Beyond establishing new limits on resident hours, the standards drafted by the task force (Table 1Table 1
Comparison of Selected Sections of the Proposed ACGME Requirements with the 2003 Standards and the IOM Recommendations.) emphasize the importance of faculty supervision and teaching, improvement of the patient handover process, and education of residents about how to manage alertness as part of their professional obligation. (An unabridged version of the task force standards is available with the full text of this article at NEJM.org.) Illness and the need for medical care are unpredictable, and circumstances arise when physicians must overcome fatigue to help patients in need. Even more important is the obligation of resident physicians to realize the effect that activities outside the program have on their alertness when in their roles as learners and providers of care. Without this cognizance, additional limits on hours may leave residents with fewer hours of teaching, practice, and professional socialization but may not help to provide the increased rest and alertness that are the intent of duty-hour limits.The standards affirm the responsibility of faculty to make sure that residents are prepared for the independent practice of medicine. Faculty are also responsible for ensuring that clinical responsibilities are not so overwhelming — in terms of time or task — as to render residents unable to learn or to provide their patients with high-quality care. The new standards address differences in capabilities and practices for first-year residents, placing more restrictive limits on their hours and requiring added supervision. These changes were made on the basis of testimony presented to the task force about the capabilities and supervisory needs of first-year residents, data from the ACGME resident survey showing that first-year residents have longer work hours than any other cohort of residents,12 and scientific evidence showing that fatigue affects the frequency of errors committed by first-year residents.13 As residents mature in knowledge, experience, and clinical judgment, the standards permit them to gradually move from a structured, directly supervised, time-limited setting to more advanced training, then to the independent practice of medicine, in which the structure of work and the allotment of time are dictated by patients' needs and physician professionalism. This progression logically begins with a more highly controlled first year of residency. The task force ultimately rejected the idea of adjusting the limits on duty hours according to specialty because studies have not shown that the safety effect of current standards varies with specialty7-9 and because the standards establish the maximum number of hours that residents may work. Specialties with less demanding requirements for education and patient care could easily be accommodated within the proposed limits, and residency review committees may choose to set more restrictive limits, as is already being done in some specialties, such as emergency medicine. Another important reason for rejecting limits based on specialty is the complexity this consideration would add to the processes of institutional monitoring and enforcement.
A worrisome element of the IOM report was criticism of the ACGME's enforcement of the 2003 duty-hour limits.10 The ACGME independently identified the difficulty of enforcement as a problem, along with the inherent challenges of enhancing the frequency and intensity of duty-hour surveillance at the program level, given the nearly 9000 accredited programs. Recognition of the need for enhanced measures to promote compliance has led to a new program of annual site visits to sponsoring institutions, focusing on duty-hour compliance, supervision, and provision of a safe and effective environment for care and learning. Experts in safety, sleep medicine, and graduate medical education are collaborating to facilitate a realistic analysis of institutions' ability to provide a safe and effective learning environment. The ACGME will provide each institution with a report that details its compliance status and identifies noncompliance issues for timely resolution. The plan is to make these results available to the public.
The goal of the ACGME's new approach to duty hours is to foster a humanistic environment for graduate medical education that supports learning and the provision of excellent and safe patient care. The graduate medical education community has a moral responsibility to prepare residents to practice medicine outside the learning environment, where they will be unsupervised, must think independently, and must function when fatigued.14
In its 2003 report Crossing the Quality Chasm, the Institute of Medicine recommended a broad-based, systems approach to patient safety.15 The planned approach combines enhanced limits on duty hours for first-year residents, graduated supervision requirements, improvement of transfers of care, enhanced expectations related to professionalism and fitness for duty, and involvement of residents in a culture of care that embodies reliability, quality, and safety. The ACGME's new comprehensive standards will enhance the quality and safety of patient care in teaching hospitals, meet the clinical educational needs of residents, and benefit the future quality and safety of care when residents trained under the new standards enter independent practice.
The standards will be available for comment until August 9, 2010, on the ACGME Web site (http://acgme.org). The ACGME welcomes input from both the educational community and the public. The task force will consider all comments and make modifications as needed. The enhanced standards will be put into effect in July 2011, at which time institutional site visits will also begin.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
This article (10.1056/NEJMsb1005800) was published on June 23, 2010, at NEJM.org.
Source Information
From the Duty Hour Task Force of the Accreditation Council for Graduate Medical Education (ACGME) (T.J.N., S.H.D., E.S.A.); and the ACGME Council (E.S.A.) — both in Chicago; Jefferson Medical College, Philadelphia (T.J.N.); the Department of Ophthalmology, California Pacific Medical Center, San Francisco (S.H.D.); and the Department of Radiology, Albert Einstein College of Medicine, and Montefiore Medical Center, Bronx, NY (E.S.A.).
Address reprint requests to Dr. Nasca at 515 N. State St., Suite 2000, Chicago, IL 60654.
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- Letters
