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Critique of Duty Hour Requirements

A Bridge too Far: A Critique of the New ACGME Duty Hour Requirements

The issue of resident work hours has been discussed extensively for more than 25 years.(1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) Errors and signs of sleep deprivation in residents have been catalogued in a few single institution studies with a limited number of residents and a modest number of observations.(5, 8, 9, 11) The results have been contradictory with some studies showing fewer errors with more mandated sleep time and one recent study showing increased length of stay and lower quality of care for patients with shorter duty shifts.(8, 9, 11) Over recent years, resident on-call duty hours spent in the hospital have been progressively reduced in response to requirements imposed by the Accreditation Council for Graduate Medical Education (ACGME), a non-governmental regulatory agency. These mandated changes in residency hours are being strictly enforced even though there is a remarkable paucity of outcomes data supporting these new rules. This year, the rules have become so stringent that they have forced training programs into what we and many others think may be a detrimental and dangerous situation for our patients. The number of consecutive hours and the number of patients that can be seen in a 24-hour period have been so restricted that many, if not most, patients admitted by residents are subjected to multiple physician changes during their first 24 hours in the hospital. This process of multiple patient hand-offs reminds me (JA) of what an old friend who was a high school football coach once told me: “The more hand-offs that are called for in a single play, the more likely there will be fumbles.”

We are convinced that this is now the situation on the in-patient services of all US post-graduate hospital training programs. We have yet to speak with anyone involved in resident training in any specialty that supports the new highly restrictive on-call hour requirements. Surgical faculty are particularly disturbed by shift work in the operating room. These colleagues and professional acquaintances are convinced that the new system will inevitably lead to many “fumbles” with increased likelihood of patient harm.

Like many of the current readers of The American Journal of Medicine, we trained in a very different era when residents spent 36 out of every 48 hours in the hospital taking care of in-patients. Please do not misunderstand us: we are not calling for the return of this form of cruel and unusual punishment in our training programs. What we are calling for are studies to examine the impact of the currently mandated system in comparison to what was required just 1 year ago. At that time residents were allowed to work only 80 hours per week, spending every 5th night in the hospital. In addition, residents were allowed to remain in the hospital, taking continuous on-call, for a maximum of 30 hours. In my opinion, this system allowed ample time off from call to recover from the 30-hour stint in the hospital.

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— Joseph S. Alpert, MD (Editor-in-Chief, The American Journal of Medicine)
William H. Frishman, MD (Supplements Editor, The American Journal of Medicine)

This article originally appeared in the January 2012 issue of the The American Journal of Medicine.

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