NOTES FROM THE ASSOCIATION OF MEDICAL
SCHOOL PEDIATRIC DEPARTMENT CHAIRS, INC.
Resident Duty Hour Restrictions: Is Less
LUC P. BRION, MD, JOSEF NEU, MD, DAVID ADAMKIN, MD, EDUARDO BANCALARI, MD,
JAMES CUMMINGS, MD, SUSAN GUTTENTAG, MD, SANDRA JUUL, MD, PHD,
VICTORIA F. NORWOOD, MD, AND RITA M. RYAN, MD
training of physicians wishes to comment on the further restriction
of duty hours recently recommended by the Institute of Medicine.1
Concern for patient safety prompted the 2003 Accreditation
Council for Graduate Medical Education (ACGME) restric-
tions on resident duty hours to 80 per week, with no longer than
30 hours allowed in 1 stretch. These ACGME restrictions were
established despite unresolved issues about the 1989 template,
the New York State regulations Section 405.4. These issues
included concerns about negative impacts on surgical training
and quality, continuity of patient care, and professionalism.2,3
Many educators have already expressed concern that the rigidity
of the current work hour limit conveys a lack of professional
responsibility, instills a detachment of physicians from patients,
and will ultimately change the culture of medicine by disrupting
the physician-patient relationship.3,4The perceived risk is that
newly trained medical professionals may become “shift workers,”
rather than professionals dedicated to their patients. Despite
such concerns about current regulations, further decreases and
restrictions in duty hours have recently been proposed by the
Institute of Medicine (IOM).1
Several cogent arguments about the impact of further
decreases in duty hours need to be raised, including negative
consequences on patient care, the education of future specialists
and subspecialists, workforce, and the entire health care system.
group of individuals representing the Council of Pedi-
atric Subspecialties and the Organization of Neonatal
Training Program Directors who are involved in the
Shortened shift duration and increased “cross coverage” result in
more frequent handoffs of patients, fragmentation of care, and
important educational deficiencies that negatively impact patient
care. One recent study suggests that ACGME regulations have
reduced patient safety in the intensive care unit.5Continuity of
patient care over a period of time, especially for those who are
critically ill, is essential to understanding the pathophysiology,
management, and impact of care for a specific disease and
patient. Further restrictions and consequent fragmentation of
duty hours will increase the frequency with which trainees must
leave while their patient is experiencing significant change that
would benefit greatly from caregiver continuity.
Further restriction or fragmentation of duty hours may
also negatively impact the competency of trainees in the early
recognition, resuscitation, and stabilization of the acutely ill
patient. For example, neonatal intubation, a critical skill once
expected to be mastered by Postgraduate Level 2, is now per-
formed with poor success rates by senior residents.6-8This may
be a factor in “trained” pediatricians, despite being credentialed
to provide acute care, choosing practices in which such care is
instead provided by in-house physicians (ie, neonatologists, hos-
pitalists, intensivists). Furthermore, the judgment of when to
apply these skills is best acquired over time in a patient care
setting. Decreased duty hours are likely to affect patient care in
ing into practice settings without the benefit of support and super-
vision from nurse practitioners, fellows, or attending physicians.
A major area of concern is the decreased one-on-one
contact between trainees and families so important to the
development of the doctor-patient relationship. These inter-
actions require time and must occur when all parties are
appropriately prepared and engaged. Trainee focus on com-
pletion of a work-list by an imposed deadline inappropriately
prioritizes physician “needs” over patient needs. Learning
how to effectively talk with patients and families is unlikely to
occur in the face of a ticking stopwatch.
The ACGME has not differentiated level of training as
applied to duty hours, nor does the current IOM statement.
There is no recognition that the educational focus of an intern is
quite different from a third-year fellow. Similarly, there is no
recognition that the responsibilities of an on-call intern are very
different from a third-year fellow. Subspecialty fellows in critical
From the University of Texas Southwestern Medical Center (L.B.), Dallas, TX, University of
Florida College of Medicine (J.N.), Gainesville, FL, University of Louisville (D.A.), Louisville,
KY, University of Miami (E.B.), Miami, FL, East Carolina University (J.C.), Greenville, NC,
Children’s Hospital of Philadelphia (S.G.), Philadelphia, PA, University of Washington (S.J.),
Seattle, WA, University of Virginia Children’s Hospital (V.N.), Charlottesville, VA, and the
University at Buffalo, State University of New York; Women & Children’s Hospital of
Buffalo (R.R.), Buffalo, NY.
*This Commentary has been endorsed by the following organizations: American College of
Rheumatology Pediatric Executive Committee; American Society of Pediatric Nephrology;
Child Abuse Program Directors; North American Society for Pediatric Gastroenterology,
Hepatology and Nutrition; Organization of Neonatal Training Program Directors; Pediatric
Infectious Diseases Society; Society of Critical Care Pediatric Section; Society of Pediatric
Cardiology Training Program Directors; and American Pediatric Society.
Reprint requests: Josef Neu, MD, 1600 SW Archer Rd, Department of Pediatrics, University
of Florida College of Medicine, Academic Research Building Room RG130, Gainesville, FL
32610. E-mail: firstname.lastname@example.org.
(J Pediatr 2009;154:631-2)
care specialties must have the opportunity to manage greater
numbers of patients with increasing complexity/acuity and be
able to assume a more prominent role in counseling patients and
their families. Having mastered basic technical skills during
residency, they must have the opportunity to develop a more
specialized technical skill set. The ACGME and American
Board of Pediatrics requirements for scholarly activity also re-
junior trainees and to become knowledgeable in research. From
a practical standpoint, theroleofthefellowmorecloselyresembles
the role of the attending subspecialty physician than it does resi-
dents. However, the inflexibility of the current and proposed duty
hour restrictions conflicts with the unique educational needs of the
levels of training, making it increasingly difficult to support the
scholarly mission and foster the development of autonomy in sub-
specialty trainees. Despite a body of literature on the impact of the
current ACGME regulations on residency training, there are no
data on the impact of duty hour limitations on the training of
pediatric subspecialty fellows. It is our opinion that subspecialty
fellows, owing to their increased age and maturity, as well as expe-
rience from prior residency training, should be allowed to manage
their duty hours with more autonomy than more junior trainees.
The simplest of solutions, to extend training, has poten-
tially grave consequences. Our trainees already struggle to handle
the massive educational debt of college and medical school.9Our
current health care system already underfunds training of spe-
cialists and subspecialists, and longer training would only in-
crease those costs.10To meet patient care demands, we antici-
pate the need for significant increases in physician numbers to
counteract the decreased work hours expected by the younger
generations. There are currently few considerations of the costs
in effort, time, and dollars that these increases will require. In his
commentary responding to the recent report, Iglehart11noted
that the IOM model estimating the number of additional full-
time equivalent positions needed to supplement the resident
workforce includes up to 5984 mid-level providers, 5001 attend-
ing physicians, or 8247 additional residents. The use of alterna-
tive providers to cover trainee activities may be problematic,
especially in light of recent concern over the effects of fatigue on
nurse practitioners. The National Association of Neonatal Nurse
Practitioners is considering a formal policy on fatigue12that may
well further fragment patient care and limit the available pool of
not be an option for highly specialized tertiary and quaternary
care or for subspecialties in which dangerous shortages already
exist.13-15Nurse practitioners are recruited from the pool of staff
nurses, another group noting significant shortages.
The increased cost of duty hour regulations to teaching
hospitals, especially during our current fiscal crisis, will be sig-
to medical care for many is likely to be negatively affected.
A broader assessment of the impact of duty hour restric-
tions needs to be considered, including effects on more senior
physicians. Much of the workload created by reduced trainee
duty hours has been taken up by more senior physicians, fre-
quently in their 50s and 60s. In fact, nephrology fellows have
noted that growing faculty workload is decreasing their interest
in continuing in the field.17The risk to patients from fatigued
attending physicians should also be considered.
With little objective evidence that the current restrictions
in the United States or abroad have improved outcomes and that
recommendations.18-28Limitations of many studies include poor
design, small sample size, and poor compliance.29We strongly
recommend expanded, meticulous research to gather and assess the
impact of the current duty hour restrictions, including evaluation of
the quality of the current “product” of our training programs.
We advocate that a broader spectrum of issues be consid-
ered in the debate on trainee work hours and be addressed with
evidence-based approaches. If there is insufficient evidence, reg-
ulatory agencies should facilitate quality research to provide the
needed evidence. It is inappropriate to base policy on small
numbers of underpowered, poorly controlled studies. Major ef-
forts should focus on benchmarking methods for adult teaching
within the context of limited duty hours. Areas requiring further
study include supervision, fatigue metrics, computerized30and
bedside hand-off methods, multidisciplinary rounds, patient
flow, acuity metrics, methods of adapting patient load to pro-
vider pools, effective use of shifts and alternative care providers
(nurse practitioners, physician assistants, general pediatricians,
hospitalists, and subspecialists), efficacy of simulation training,
prevention of medical errors, and, importantly, patient satisfac-
tion and patient outcomes. Cost-benefit analyses are needed to
address the impact of changing duty hours on the larger health-
care system. A balanced examination of the effectiveness of
shorter duty hours on graduating trainees and educators in other
countries is needed.31,32To act on anything less than objective,
evidence-based data would be irresponsible and detrimental to
our patients and their families.
It is our opinion that proceeding with additional regula-
tions without appropriate evaluation of current outcomes and
without advanced planning to determine optimal infrastructure,
resources, methods, personnel, and scheduling required to opti-
mize the training of new specialists and subspecialists gravely
risks the delivery of patient care and the future of medical
education and research. We urge the ACGME and IOM to
reconsider broadly applying duty hour restrictions without con-
sidering level of training, allowing more advanced subspecialty
trainees the autonomy that advanced educational objectives re-
quires. Most importantly, we recommend that the current duty
hour rules be evaluated by rigorous scientific methods before
implementation of any new regulations at the national level.
References are available at www.jpeds.com.
0022-3476/$ - see front matter
Copyright © 2009 Mosby Inc. All rights reserved.
632Brion et alThe Journal of Pediatrics • May 2009
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