ACGME Work Hours

For anyone who has spent time in the hospital, the not-so-well-kept secret is that residents are the ones you’re likely to see most often. About 25% hospitals have residents according to the ACGME, and percentage increases when you look Critical Access Hospitals.

Residents are the grunts of the medical world. They are full-fledged MDs who work worse hours for less pay than most nursing staff. Residents are the ones in the hospital overnight admitting patients and they are probably some of the first people you see in the morning as they run around trying to keep a lid on everything before the attending, or chief physician, to get to the hospital.

The Accreditation Council for Graduate Medical Education runs the majority of residencies. In 1989, the ACGME instituted an 80-hour work week limit for internal medicine. A decade later, the infamous Institute of Medicine “To err is human” study was published documenting the hundreds of thousands of deaths that occur from medical errors in hospitals. In response to this study, in 2003, the ACGME instituted common duty hour restrictions of a maximum of 80 hours per week.

The ACGME just reversed this maximum due, in large part, to the results of the FIRST Trial. To summarize, the study, which stands for Flexibility In duty hour Requirements for Surgical Trainees Trial, found no statistical difference between the two arms with respect to patient safety or physician well being. As the name implies, this study looked only at surgical residencies.

Based on this study, and without waiting for the similar study looking at internal medicine residencies, the ACGME came out recently with a 24hr cap on first year duty hours and a 28hr cap thereafter. Both these caps have an additional 4hr handoff window.

There are a few problems with the study, as I see it. The major flaw being that the study tested only maximum duty hours 16 vs 24. There may be no difference in patient safety and physician well-being between 16 and 24 hour work schedules, but an 8 or 12 hour shift might have made a difference. This is like comparing a 15,000 calorie diet and a 12,0000 calorie diet and exclaiming that the patient is still obese. But he/she reduced the number of calories! Well not enough to make a difference. The same is true of the FIRST Trial: it is entirely plausible that there is no difference between a 16 and 24 hour shift, but reducing hours to 12 hour shifts or, G-d forbid, 8 hours would have resulted in better outcomes; or worse, but we won’t know because this study only tested maximum duty hours.

There is ample evidence on the negative impacts of lack of sleep. So why didn’t these show up in the study? We can’t know for sure, but the other not-so-well-kept secret of medicine is that no one accurately reports his/her hours. Everyone works under 80 — no matter what. Even as a medical student, when I worked over 80 hours in a week, it never crossed my mind to report more than 80. If you are consistently working more than 80 hours per week, residents talk to their program directors or attendings; they do not report it to the ACGME because reporting reflects negatively on the program, which the resident is a part of.

The incentives of the ACGME and the data in the FIRST trial is questionable. Having more residents in the hospital is better for everyone but the residents. Residents are cheap workhorses that keep patients moving through hospitals. The incentive for residents is to underreport to the ACGME for fear of pushback and a martyr’s mentality prevalent in medicine, making the ACGME data suspect. I would have loved to see the ACGME compare 8–12 hour shifts vs 16 and 24, but that will never happen because hospitals run on residents and residents have no readily available form of recourse.