ACGME duty-hour recommendations - a national survey of residency program directors.

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Perspective
The NEW ENGLAND JOURNAL of MEDICINE
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Medical Education (ACGME) re-
cently published proposed new
recommendations,2 which, as
eventually approved, would go
into effect in July 2011. These
recommendations represent a
continuing commitment by the
ACGME to both “foster a human-
istic environment for graduate
medical education” and ensure
“excellent and safe patient care.”2
The ACGME has solicited com-
ments from the educational com-
munity and will modify its pro-
posal as needed.
The recommendations repre-
sent an attempt to address ele-
ments of the 2003 ACGME stan-
dards that generated widespread
criticism, raising questions about
conflicts between duty-hour lim-
its and professional responsibil-
ities to patients, the lack of
changes in the larger learning
environment, and the debate over
the effects of sleep loss.2 It re-
mains unclear, however, whether
residency program directors, who
are responsible for overseeing
graduate medical education, agree
with and are prepared to imple-
ment the ACGME’s recommenda-
tions. Moreover, residency pro-
grams are heterogeneous, varying
not only in size but also in spe-
cialty — and, therefore, in requi-
site education and training. As a
result, residency program direc-
tors from various specialties may
react to the new recommenda-
tions quite differently from one
another. Although physicians tend
to agree in the abstract that better-
rested residents provide better and
safer care, program directors may
be unwilling to endorse the pro-
posed restrictions on the num-
ber and continuity of duty hours.
In July 2010, we attempted to
survey all 823 U.S. residency pro-
gram directors in internal medi-
cine, pediatrics, and general sur-
gery (see Table 1). As part of a
three-section, self-administered
e-mail questionnaire on the pro-
posed duty-hour recommenda-
tions, program directors respond-
ed to 22 items related to the
new requirements and indicated
which proposals were already
operative within their programs.
They were asked to indicate their
level of agreement or disagree-
ment with specific proposals from
the 11 categories specified by the
ACGME: supervision, workload,
ACGME Duty-Hour Recommendations — A National Survey
of Residency Program Directors
Ryan M. Antiel, M.A., Scott M. Thompson, B.A., Darcy A. Reed, M.D., M.P.H, Katherine M. James, M.P.H.,
Jon C. Tilburt, M.D., M.P.H., Michael P. Bannon, M.D., Philip R. Fischer, M.D., and David R. Farley, M.D.
T
dents’ duty hours,1 the 16-member Duty Hour Task
Force of the Accreditation Council for Graduate
aking into consideration the Institute of Medi-
cine’s 2008 recommendations regarding resi-
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PERSPECTIVE
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e12(2)
maximum hours per week, max-
imum length of duty period, in-
hospital call frequency, minimum
time off between scheduled duty
periods, maximum frequency of
in-hospital duty, mandatory off-
duty time, moonlighting, duty-
hour exceptions, and home call
(see Table 2 for the specific pro-
posals).
We found publicly available
e-mail addresses for 742 of the
directors of the 823 programs in
medicine, pediatrics, and surgery
in the United States and Puerto
Rico, but 23 (3%) of these ad-
dresses were nonfunctional. Of
the remaining 719 eligible par-
ticipants, 429 returned completed
surveys within 2 weeks, for a re-
sponse rate of 60%. Response
rates did not vary significantly
among specialties: 187 of 308
(61%) in medicine, 118 of 189
(62%) in pediatrics, and 124 of
222 (56%) in surgery responded.
As Table 2 shows, a large ma-
jority of respondents agreed with
the ACGME recommendations re-
garding mandatory off-duty time
(94%), workload (92%), and moon-
lighting (93%). Most also agreed
with the specific proposals re-
garding maximum hours per week
(83%), maximum frequency of in-
hospital duty (74%), supervision
(72%), minimum time off be-
tween scheduled duty periods
(67%), and home call (63%). By
contrast, only 14% agreed with
the ACGME’s proposal for a max-
imum duty period of 16 hours
for first-postgraduate-year (PGY-1)
residents. Program directors were
divided regarding whether excep-
tions allowing up to 88 duty
hours per week should be per-
mitted for selected programs (49%
agreed, 29% disagreed, and 22%
were neutral).
Currently, the vast majority of
programs (94%) do not adhere
ACGME Duty-Hour Recommendations
Table 1. Characteristics of the 429 Survey Respondents.*
CharacteristicNo. (%)
Male sex 295 (69)
Age
<50 yr187 (44)
≥50 yr 242 (56)
Region
Northeast153 (36)
Midwest110 (26)
South 100 (23)
West 66 (15)
Field
Medicine187 (44)
Surgery124 (29)
Pediatrics118 (28)
Specialty
General internal medicine, general pediatrics,
or general surgery
322 (75)
Other specialty 107 (25)
Academic rank
Instructor 6 (1)
Assistant professor 83 (19)
Associate professor169 (39)
Professor 149 (35)
Other 22 (5)
Years as program director
0–5175 (41)
6–10114 (27)
11–15 69 (16)
16–20 46 (11)
>2025 (6)
Average hours per week of direct teaching
or supervision of residents
0–5 14 (3)
6–10 87 (20)
11–15 92 (21)
16–20 89 (21)
>20 147 (34)
Program type
Large university-based 160 (37)
Small university-based 47 (11)
Large community-based 30 (7)
Small community-based 49 (11)
Community hospital, university-affiliated127 (30)
Other16 (4)
* Percentages may not sum to 100 because of rounding.
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PERSPECTIVE
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to a 16-hour limit for the duty
period in PGY-1. Similarly, the
majority of programs (70%) do
not have policies in place regard-
ing duty-hour exceptions. A sub-
stantial minority of programs have
not implemented the ACGME’s
recommended changes in super-
vision (29%), home call (25%), in-
hospital on-call frequency (25%),
or maximum frequency of in-
hospital duty (16%).
In multivariate logistic-regres-
sion models, academic rank, years
as program director, and average
hours per week spent in direct
teaching or supervision of resi-
dents were not significantly asso-
ciated with responses to ACGME
proposals, but the program di-
rectors’ age, specialty, and pro-
ACGME Duty-Hour Recommendations
Table 2. Distribution of Responses to Key ACGME Categories and Whether or Not the Standards in Question Are Already in Place.*
Category ProposalProgram Directors’ Responses to Proposal
Standard Already
in Place?
Strongly
Disagree
Moderately
DisagreeNeutral
Moderately
Agree
Strongly
AgreeYes No
no. (%)
Supervision PGY-1 residents must have
direct supervision from
an M.D. who is physically
present with the resident
or the supervising M.D.
must be on site and avail-
able to provide direct
supervision
33 (8) 53 (13) 32 (8) 115 (27)191 (45)297 (71) 122 (29)
WorkloadLearning objectives must not
be compromised by exces-
sive nonphysician service
obligations
3 (1) 7 (2)22 (5) 119 (28)273 (64) 380 (91) 39 (9)
Maximum hr/wkMaximum duty of 80 hr/wk,
averaged over 4 wk
11 (3)25 (6)36 (8)172 (41)180 (42)415 (99) 4 (1)
Maximum length
of duty period
Duty periods for PGY-1 residents
must not exceed 16 hr
239 (56) 96 (23) 29 (7) 39 (9)21 (5) 26 (6)393 (94)
In-hospital on-call
frequency
Residents in PGY-2 or later
years limited to in-hospital
on-call frequency of every
third night, with no aver-
aging
51 (12) 50 (12) 30 (7)135 (32) 158 (37) 316 (75)103 (25)
Minimum time off
between scheduled
duty periods
Residents should have 10 hr
off between duty shifts and
must have 8 hr free of duty
between duty periods
19 (4) 58 (14) 63 (15)172 (41) 112 (26) 393 (94)26 (6)
Maximum frequency
of in-hospital duty
Residents must not be sched-
uled for more than 6 con-
secutive nights of night duty
22 (5)36 (8) 53 (13)162 (38)151 (36)352 (84) 67 (16)
Mandatory off-duty
time
24 hr off per 7-day period,
when averaged over 4 wk
2 (0.5) 7 (2) 18 (4)148 (35)249 (59)416 (99) 3 (1)
MoonlightingPGY-1 residents must not be
permitted to moonlight
4 (1) 9 (2) 17 (4) 33 (8) 361 (85)387 (92)32 (8)
Duty-hour exceptions Duty-hour exceptions up to 88
hr/wk averaged are permis-
sible for selected programs
with a sound educational
rationale
47 (11) 76 (18) 95 (22)105 (25) 101 (24) 125 (30) 294 (70)
Home call Time on home call spent by
residents in hospital must
count toward 80-hr maxi-
mum weekly limit
50 (12) 41 (10) 66 (16) 116 (27)151 (36)313 (75)106 (25)
* Numbers may not sum to 429 because not all respondents answered all the questions. PGY denotes postgraduate year.
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gram type were. As shown in
Table 3, general surgery program
directors were one fifth as likely
as internal medicine program di-
rectors to agree with the ACGME
proposed mandates limiting the
maximum duty hours per week
to 80 and the maximum length
of the duty period for PGY-1 res-
idents to 16 hours. Surgery pro-
gram directors were also half as
likely as internal medicine pro-
gram directors to agree that resi-
dents should not be scheduled for
more than six consecutive nights
of duty (maximum frequency of
in-hospital duty). Directors of pe-
diatrics and surgery residencies
were less likely than directors of
internal medicine residencies to
agree with the proposal for an
in-hospital on-call frequency of
every third night, with no averag-
ing allowed, for residents in PGY-2
and later years (odds ratios, 0.5
and 0.1, respectively). However,
they were more likely to agree with
including time spent on home
call in the 80-hour weekly limit
(odds ratios, 1.7 for pediatrics and
1.6 for surgery). Surgery program
directors were half as likely —
but pediatrics program directors
were nearly twice as likely — as
internal medicine program direc-
tors to agree with the proposal
for minimum time off between
scheduled duty periods.
Program directors 50 years of
age or older were less likely than
their younger counterparts to
agree with including time on
home call in the 80-hour weekly
limit (odds ratio, 0.6) and more
likely to agree with limiting the
maximum length of the duty pe-
riod for PGY-1 residents to 16
hours (odds ratio, 1.8). Program
directors who spend more than
15 hours per week directly teach-
ing or supervising residents were
significantly less likely than those
who spend less time working with
residents to agree with the pro-
posal for in-hospital on-call fre-
quency of every third night, with
no averaging, for residents in
PGY-2 or later years, as well as
the proposal that time on home
call should be included in the
ACGME Duty-Hour Recommendations
Table 3. Odds of Endorsing Key ACGME Category Proposals, According to Age, Field, Average Number of Hours Per Week Spent Supervising
Variable Category
SupervisionWorkload Maximum hr/wk
Maximum Length
of Duty Period
In-Hospital On-Call
Frequency
odds ratio (95% confidence interval)
Age
<50 yr RefRef RefRef Ref
≥50 yr1.1 (0.7–1.8)1.0 (0.5–2.2)0.9 (0.5–1.5) 1.8 (1.0–3.3)†0.7 (0.4–1.0)
Field
MedicineRef RefRef RefRef
Pediatrics 0.7 (0.4–1.3)0.8 (0.3–1.9)0.9 (0.4–1.9) 0.7 (0.3–1.3) 0.5 (0.3–0.8)†
Surgery0.6 (0.4–1.1)1.0 (0.4–2.4) 0.2 (0.1–0.3)† 0.2 (0.1–0.5)† 0.1 (0.1–0.2)†
Average hr/wk of direct teaching or
supervision of residents
0–15RefRefRef RefRef
>150.8 (0.5–1.2)0.4 (0.2–1.0)0.7 (0.4–1.2) 0.6 (0.4–1.1) 0.6 (0.4–1.0)†
Program type
Large university-based RefRefRefRefRef
Small university-based 0.7 (0.4–1.5)‡0.9 (0.4–2.0) 0.6 (0.2–1.8)0.9 (0.5–1.9)
Large community-based1.8 (0.6–5.0)1.5 (0.3–7.0)0.8 (0.3–2.2)0.7 (0.2–2.3) 1.2 (0.5–2.7)
Small community-based 0.5 (0.2–0.9)† 1.3 (0.4–4.1)0.7 (0.3–1.7) 0.2 (0.04–0.8)† 0.6 (0.3–1.3)
Community hospital, university-
affiliated
1.1 (0.6–2.0)1.1 (0.5–2.6) 1.2 (0.6–2.3)0.9 (0.5–1.7)1.3 (0.8–2.3)
Other1.1 (0.3–3.5)‡0.8 (0.2–3.2)0.7 (0.1–3.2) 6.9 (0.9–54.4)
* All odds ratios have been adjusted for age (as a continuous variable), sex, and geographic region. Ref denotes reference group.
† P<0.05.
‡ Odds ratio and confidence interval cannot be estimated because of small numbers.
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PERSPECTIVE
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80-hour weekly limit (odds ratio
in both cases, 0.6). Finally, as com-
pared with directors of large,
university-based programs, direc-
tors of small, community-hospital–
based programs were significant-
ly less likely to agree both with
the recommended supervision re-
quirements (odds ratio, 0.5) and
with limiting the maximum length
of the duty period for PGY-1 resi-
dents to 16 hours (odds ratio, 0.2).
These data provide insight into
the attitudes of those who will be
charged with implementing any
new duty-hour recommendations.
First, although large proportions
of residency program directors
agree with several of the recom-
mendations, especially those per-
taining to such topics as total
workload, off-duty time, and max-
imal hours, a similarly large pro-
portion disagree on more specific
aspects of the proposed changes,
such as limiting the duty period
for PGY-1 residents to 16 hours.
Second, most residency programs
currently lack the policies and
plans necessary for compliance
with the proposed new require-
ments, which suggests that most
will need to radically overhaul
schedules and curricula in order
to comply with new recommenda-
tions by the proposed July 2011
implementation date. Third, sur-
gery program directors were con-
siderably less enthusiastic about
both the 80-hour workweek re-
quirement and the 16-hour duty-
period limit than their counter-
parts in internal medicine and
pediatrics. These differences may
reflect differences in specialty
culture as well as pragmatic con-
siderations pertaining to the na-
ture of specialty workflow that
may limit the feasibility of im-
plementing the proposed duty-
hour requirements. Finally, our
finding that directors of small
programs at community hospitals
are less enthusiastic about limit-
ing the duty-hour period may sug-
gest that implementation may face
more challenges in such settings.
The diverse opinions expressed
by program directors reflect lin-
gering concerns and tensions over
balancing residents’ fatigue and
patients’ safety and well-being
against the demands of educa-
tional quality, financial costs, and
the need to instill professional
responsibility. Some have argued
ACGME Duty-Hour Recommendations
or Teaching Residents, and Program Type.*
Category
Minimum Time Off between
Scheduled Duty Periods
Maximum Frequency
of In-Hospital Duty
Mandatory Off-Duty
Time MoonlightingDuty-Hour Exceptions Home Call
odds ratio (95% confidence interval)
RefRef RefRef Ref Ref
1.2 (0.8–1.8)1.3 (0.8–2.0)1.7 (0.8–3.7)2.2 (1.0–4.6) 1.2 (0.8–1.8) 0.6 (0.4–1.0)†
RefRef RefRefRefRef
1.9 (1.1–3.3)†1.1 (0.6–1.9)1.7 (0.5–5.7) 1.2 (0.5–3.2)1.0 (0.6–1.7) 1.7 (1.1–2.9)†
0.5 (0.3–0.8)† 0.5 (0.3–0.9)†0.5 (0.2–1.1)1.1 (0.5–2.6)1.3 (0.8–2.1) 1.6 (1.0–2.6)†
Ref RefRefRefRefRef
0.9 (0.6–1.4)0.9 (0.5–1.3)1.2 (0.5–2.6)0.9 (0.4–1.9) 1.0 (0.7–1.5) 0.6 (0.4–0.9)†
Ref RefRef RefRefRef
2.0 (0.9–4.3)1.0 (0.5–2.1)1.0 (0.3–3.8) 1.2 (0.3–4.6)0.6 (0.3–1.1)0.7 (0.3–1.3)
1.0 (0.5–2.3)0.8 (0.3–1.9)0.4 (0.1–1.5)0.3 (0.1–1.0)0.8 (0.4–1.8)0.4 (0.2–1.0)
1.2 (0.6–2.3)0.7 (0.4–1.5)0.7 (0.2–2.4)1.9 (0.4–8.7)0.8 (0.4–1.5)0.7 (0.3–1.4)
1.3 (0.8–2.3)1.7 (0.9–3.0) 1.3 (0.4–3.79)1.4 (0.5–3.6)0.6 (0.4–1.0)0.7 (0.4–1.1)
1.3 (0.4–4.1) 1.6 (0.4–6.1)‡‡1.1 (0.4–3.0)0.7 (0.2–2.0)
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e12(6)
that despite the financial costs
and the necessary restructuring
of clinical work, the ACGME
should limit duty hours just as
other hazardous industries do.3
Recent studies, however, fail to
show that the restrictions enact-
ed in 2003 had a positive effect
on patient safety.4 This uncer-
tainty about demonstrable effects
on outcomes may explain some
of the disagreement we saw. Fur-
ther work is needed to describe
the outcomes associated with var-
ious duty-hour designs. Finally,
our finding that surgery program
directors are more likely than
other directors to disagree with
the requirements regarding max-
imum work hours and length of
duty period is of a piece with
previous efforts by the American
College of Surgeons to empha-
size differences among training
programs in different specialties.5
Although our data indicate that
program directors are divided re-
garding exceptions permitting
residents to work up to 88 hours
per week, such an option would
provide flexibility for certain
specialties.
Of course, our study has some
important limitations. Associa-
tions found in a cross-sectional
study cannot establish causal re-
lationships. The attitudes of the
program directors who did not
respond to the survey may be dif-
ferent from those of directors who
did respond. Our results reflect
only the perspectives of program
directors in internal med icine,
pediatrics, and general surgery,
not all specialties. Also, we mea-
sured the degree of agreement
on only one proposal from each of
the 11 categories of recommen-
dations.
Nevertheless, our results sug-
gest that although the majority
of program directors agree with
the overall workload recommen-
dations, they disagree regarding
limiting duty periods to 16 hours
for PGY-1 residents. More work
addressing the different needs of
the various specialties and pro-
gram types may be required to
achieve broader agreement on and
compliance with the newest duty-
hour recommendations.
Disclosure forms provided by the au-
thors are available with the full text of this
article at NEJM.org.
From the Mayo Medical School (R.M.A.,
S.M.T.); the Mayo Clinic Medical Scientist
Training Program (S.M.T.); the Mayo Clinic
Professionalism and Ethics Program (R.M.A.,
D.A.R., K.M.J, J.C.T., M.P.B.); the Mayo Clinic
Knowledge and Encounter Research Unit
(K.M.J., J.C.T.); and the Division of Primary
Care Internal Medicine (D.A.R.), the Divi-
sion of General Internal Medicine (J.C.T.),
the Department of Surgery (M.P.B., D.R.F.),
and the Division of Pediatric and Adoles-
cent Medicine (P.R.F.), Mayo Clinic — all in
Rochester, MN.
This article (10.1056/NEJMp1008305) was
published on August 4, 2010, at NEJM.org.
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1.
ACGME Duty-Hour Recommendations
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From the NEJM Archive Copyright © 2010 Massachusetts Medical Society.