The ACGME’s 2011 Changes to Resident Duty Hours:
Are They an Unfunded Mandate on Teaching Hospitals?
Patrick S. Romano, MD MPH1and Kevin Volpp, MD, PhD2
1UC Davis Division of General Medicine and Center for Healthcare Policy and Research, Sacramento, CA, USA;2Philadelphia Veterans Affairs
Medical Center, Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA.
J Gen Intern Med 27(2):136–8
© Society of General Internal Medicine 2011
Education’s (ACGME) new resident duty-hour standards.
Effective July 2011, the Common Program Requirements state
that duty hours must be limited to 80 hours per week,
averaged over a four-week period, including in-house call and
moonlighting (although exceptions may be granted up to
88 hours “based on a sound educational rationale”). Residents
must be scheduled for at least one duty-free day (without at-
home call) every week, averaged over four weeks. Duty periods
of interns must not exceed 16 hours. Upper level residents
may be scheduled up to 24 hours of continuous duty, with up
to four additional hours for transitions in care, but “strategic
napping… is strongly suggested.” PGY-1 and intermediate-
level residents must have eight duty-free hours between
scheduled duty periods, and 14 duty-free hours after
24 hours of in-house duty. Residents must not be scheduled
for more than six consecutive nights of night float, and higher
level residents must be scheduled for in-house call no more
frequently than every third night (averaged over four weeks).
Finally, the ACGME mandated changes to the training
environment to improve residents’ educational experience
and to mitigate potential adverse effects of the duty-hour
To inform the evolution of these requirements, Fletcher and
colleagues conducted a systematic review to investigate the
effect of the 2003 resident duty-hour rules on resident
education, well-being, and patient care. Twenty studies
assessed changes in mortality among medical and/or surgical
patients;2most showed no effect after accounting for secular
trends, but several showed improved mortality for patients
with four medical conditions at Veterans Affairs hospitals,3
medical patients with infectious diseases or heart failure,4and
trauma patients.5The 24 studies assessing complications had
mixed results, but “the preponderance of studies demonstrat-
ed that some outcomes improved, some worsened, and some
were unchanged.”2Several studies of resident education
reported decreased operative experience among surgical resi-
dents after 2003, but resident burnout appears to have
improved. In summary, these findings and those of another
systematic review6suggest that the 2003 rules did not have a
meaningful effect, either favorable or unfavorable, on patient
hroughout America, teaching hospitals are struggling to
meet the Accreditation Council for Graduate Medical
safety and quality-related outcomes. Of course, this conclu-
sion begs many questions, including whether the 2003 rules
showed little impact on patient outcomes because they were
too strict (causing handoff-related harms that canceled out
any benefit), because they were too lax (allowing fatigued
residents to continue harming patients), or because patient
outcomes are inherently insensitive to duty-hour regulation
(given reasonable safeguards and redundancies provided by
nurses, other trainees, and faculty). If modest reductions in
resident work hours had no impact, then would further
reductions also have no impact—because there is no true
association between resident fatigue and patient outcomes—or
would they have more impact—because resident fatigue may
then fall below a hypothetical patient safety threshold?
With this historical background, Nuckols and Escarce
attempted to estimate the direct costs (across all US hospitals)
associated with different strategies for implementing the 2011
ACGME requirements, the net costs to major teaching hospitals,
and the cost-effectiveness to society, accounting for potential
effects of reduced duty hours on preventable adverse events.7
This is an extraordinarily challenging but important task.
Skeptics have argued that the ACGME requirements will
compromise residents’ continuity of care and development of
core competencies,8while imposing a substantial unfunded
mandate with little direct evidence that quality will improve.
However, the size of this economic burden must be better
understood. If the burden is substantial, then a variety of
adverse consequences should be anticipated. For example,
teaching hospitals might mitigate this burden by reducing
expenditures in ways that might compromise patient outcomes
(e.g., by deferring capital expenditures or eliminating staff
positions). Teaching hospitals that do not have a core mission
of teaching may respond by eliminating residency programs or
de-affiliating with residency programs in their communities. Or
they may increase training positions in specialties in which work
hours are not an issue (e.g., dermatology, emergency medicine)
while reducing training positions in specialties such as internal
medicine and general surgery. Increased physician labor costs
may also force teaching hospitals to raise prices for commercial
patients, weakening their competitiveness in local markets.
Medicare’s formula for direct graduate medical education
(DGME) payments precludes teaching hospitals from passing
on ACGME-related costs to the Centers for Medicare & Medicaid
Services because the per-resident amount is based on costs
incurred in a base year period (1984 or 1985), updated annually
for inflation.9The National Commission on Fiscal Responsibility
and Reform (“Bowles–Simpson”) and other deficit reduction
plans would reduce DGME payments;10any adjustment to
cover ACGME-related costs would be a “tough sell” in the
Published online November 30, 2011
Building on a previous economic evaluation of the Institute
of Medicine’s recommendations on resident duty hours,11
Nuckols and Escarce report that duty-hour changes will cost
$177 million annually if interns maintain current productivity,
or up to $982 million annually if they transfer excess work to a
mixture of substitutes. Mandatory changes in the training
environment are estimated to cost an additional $191 million
annually. Curiously, a different analytic approach using Monte
Carlo simulation generated a higher estimate of total direct
annual costs, $1,424 million (95% confidence interval,
$1,052–1,910 million), under the mixed-substitute assump-
tion. Most importantly, Nuckols and Escarce report that a
1.9% to 6.8% reduction in preventable adverse events (PAEs)
could make the ACGME policies cost-saving for society, but
readily acknowledge that it is unknown whether any reduction
will occur. How should we interpret these estimates? What do
they mean for teaching hospitals and for society?
The critical challenge is that an economic analysis of this
type is only as good as the data that go into it, and as
defensible as the assumptions upon which it is based. While
Nuckols and Escarce made reasonable assumptions, searched
for the best cost estimates, and performed appropriate sensi-
tivity analyses, it is easy to challenge specific choices. For
example, they assumed that faculty physicians substituting
for residents are twice as efficient, earn $76.46 per hour (2008
dollars), and delegate tasks to licensed vocational nurses
earning $19.04 per hour. An equally plausible scenario is that
these physicians are only 50% more efficient, earn $89.17 per
hour (based on average 2008 compensation for hospitalists12),
and delegate tasks to registered nurses earning $31.54 per
hour.13This alternative scenario could nearly double their
estimate of labor substitution costs (Table 2, Scenario Y).
More importantly, we have very little data to inform the
central question of whether the 2011 requirements will affect
the risk of PAEs. The hypothesis that this risk will decrease is
essentially based on one randomized controlled trial showing
less fatigue14and fewer “serious medical errors”15when
interns worked 16-hour shifts instead of overnight shifts in
intensive care units, supported by laboratory-based studies
and pre-post studies of medication errors.16These findings
may not generalize to other settings because the known
hazards of care transitions17were mitigated by a nurse-to-
patient ratio of 1:1 or 1:2, because the study was underpow-
ered to compare PAE rates, and because the intervention was
discontinued when the study ended, suggesting that 16-hour
shifts were not universally embraced.18As Nuckols and
Escarce posit, the relative risk of PAEs under the 2011 policies,
compared with previous policies, could plausibly range from
0.9 to 1.1, with profoundly variant estimates of resulting net
costs, benefits, and cost-effectiveness.
Useful economic analyses of health care interventions invari-
ably describe the robustness of their cost-effectiveness esti-
mates, given plausible variation in underlying assumptions, and
highlight the parameters that have the most impact on these
estimates. Nuckols and Escarce’s analysis of the ACGE require-
ments is an unusual example, in that the intervention may be
regarded as reasonably cost-effective or extremely wasteful,
depending on two essentially unknown factors: how teaching
hospitals will “offload” excess resident work, and how shorter
shifts for interns will affect PAE rates. Until these two phenom-
ena are better understood, we are in uncharted territory and
can only speculate—albeit in a somewhat informed manner,
thanks to Nuckols and Escarce—about the economic impact.
Research is also needed to address the effects of 16-hour shifts
(versus “strategic napping”) on transitions in care, resident
learning and clinical experience, and physician professionalism.
The critical challenge for teaching hospitals, and for an
entire nation that depends on the care and education that
teaching hospitals provide, is to implement the ACGME
requirements with as little additional faculty labor as possible
(to minimize costs) and with rigorous safeguards to ensure
that the expected reduction in fatigue-related errors translates
into better patient outcomes (to maximize benefits), avoiding
the countervailing risk of more frequent handoffs. If residency
training directors and academic medical center leaders can
accomplish this feat, while preserving the ethos of care
delivery, then we may look back on 2011 as a year of upheaval
in which postgraduate medical training nonetheless became
safer, more humane, more educational, and perhaps even
Corresponding Author: Patrick S. Romano, MD MPH; UC Davis
Division of General Medicine and Center for Healthcare Policy and
Research, 4150V Street, PSSB Suite 2400, Sacramento, CA 95817,
USA (e-mail: firstname.lastname@example.org).
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Romano and Volpp: The ACGME’s 2011 Changes to Resident Duty Hours