Medical Residency Work Hours
Today I want to share about something I’ve been passionate about for years – the hours that residents work. For the unfamiliar, these are the newly graduated MDs and DOs who must work at least 3 years in a “residency” program in order to practice medicine. (While that statement is not 100% technically true, it is effectively true due to a number of cultural and business reasons.)
Residents work 60-120 hours per week in their hospitals and clinics. Yes, you read that right – they work 1.5-3 times as much as a normal American is expected to work. They also work 24-hour shifts (plus up to an extra 4 hours beyond that for “admin time” – so 28-hour shifts). Let me tell you firsthand, if you’ve ever tried to stay awake for 24 hours, you are not making the best decisions at hour 20+.
Right now, the ACGME (who ostensibly regulates residency programs and protects residents) is proposing a rule change to not only continue this insanity, but to make it just a little bit worse.
They are proposing to change the work hour rules to enable programs to schedule residents for education/work only 12 hours after a 24-hour shift. The old rule is 14 hours of rest is required. They are also proposing that residents no longer need any required rest time after a shift, the old standard being 8 hours.
Why would they do this? I have a guess – business. The simple economics is that residency programs cost a lot to administer since residents have to be scheduled and educated and supervised, but they also earn a TON of money for their hospitals. This is because hospitals can’t hire anyone else to make clinical decisions (life and death decisions) for about the same hourly rate as their housekeeping staff. By allowing the residents to work even a single extra shift in a month, the profit gains are obvious.
In my opinion, everything about the current proposed change is mirroring our current presidential administration – business first, people last.
In addition to reducing the already slim work hour requirements, the other changes to the policy include deemphasizing or eliminating much of the “aspirational language” around values like compassion, professionalism, patient autonomy, patient safety, excellent patient care, cultural sensitivity, self-improvement, and self-care. They said this was in service of brevity and that they put this information into a “guidance” document instead of here in the “requirement” document. They also removed any suggestion that faculty members should act as role models, simply leaving in that faculty should be “qualified.”
Further, they removed the requirement that programs evaluate the agreements they have with the sites where their residents train every 10 years, instead suggesting that they should just be evaluated “as needed, when changes occur, and in accordance with local policies and procedures.” They also said that programs can’t require more than 1 faculty for 5 learners. Fewer teachers is fine, but more can’t be required, since that’s too difficult for the programs to do. (Formerly, this was different by specialty, with Emergency Medicine mandating a ratio of 1 faculty to 3 learners at most, but everyone else more in line with 5-10.)
I believe these changes will make residency even more miserable. I think they are cruel and backwards, and further erode public trust in physicians. Why the hell would I trust you to tell me how to stay healthy when you work yourselves like this?
Here’s a copy of what I wrote in the public comments to the ACGME. The window for comment closes October 20, so send yours in today! The survey is set up to ask for your opinion on each section. The most important stuff is at the end.
1.3a – no period to review contracts
As a member of the public who regularly interacts with patient/clients, and as a former resident physician, I believe this level of review should be mandatory. Asking for someone to review a contract once every 10 years at minimum is far from an onerous requirement, and if there is even the chance that the review triggers an improvement in working conditions for residents, then it is worth doing. The proposed language around evaluating “as needed, when changes occur, and in accordance with local policies and procedures,” is too vague.
2.15a – PDs are not role models now
As a member of the public who regularly speaks with those most ill-served by the current healthcare system, public trust in physicians is a concern that the entire profession needs to take seriously. I believe that “aspirational” language is preferable to implying that the ACGME sees ethics as optional. In my view, changing the language here reflects a view that PDs are not more expected to be role models than the learners in their program. That’s ridiculous. Program directors should absolutely be held to a higher standard. Leaving in one sentence that states this expectation is not excessively wordy. Moving all of the value statements to a single, late section of the document may make it more concise, but having them integrated throughout shows a commitment to ethics – which I believe is more important.
2.25 – core faculty – student ratio
While I understand the intention is not to overburden programs with unnecessary restrictions, I found the inclusion of a maximum requirable ratio (max of 1 core faculty per 5 residents), but not a minimum, rather telling of profit-motivated changes to this document. If the ACGME cares about learning, protecting residents, and protecting patient safety as well as the integrity of the profession, it seems to me that this would also include an upper bound on how many residents could be distributed per core faculty. 10? 20? In my residency experience, with a program of ~30 residents and ~5 core faculty, it was very difficult to build a relationship with any of them because they were simply too busy trying to split their time among all of us. I think the ratio you have chosen is incorrect, and I find the lack of a “minimum” on the ideal proposed ratio highly concerning.
4.3 – professionalism curriculum
I find this rewrite to speak to the darkest possible motives I could imagine as a member of the general public. By deciding to add and emphasize the value of AI, while removing all other specific potential ethical or professional concerns, the message is clear. Morality is now, apparently, optional for physicians.
The ACGME requires residency programs to engage with AI use, but not in cultural competency, non-discrimination, patient safety, patient autonomy, compassion, integrity, conflict of interest disclosure, accountability, or self-care. All of those now fall under "guidance" and not "requirements."
That language speaks volumes about who this rewrite seems meant to favor - corporations. It's easy to see how AI can increase the bottom line, and it's equally easy to see how compassion, self-care, and individualized patient care, aka, things that may take non-billable physician time, hurt the bottom line.
4.8 – communication requirements went from being specific to vague, and important stuff gone.
Again, by choosing brevity over specificity here, it is clear to me that the writers do not value communication skill development. By moving content that prioritizes working with interpreters, local health agencies, other clinical professionals, patients, and families as well as developing effective leadership skills and patient partnerships from "requirements" to "guidance," it's clear that the ACGME sees humans as expendable and unimportant. Effective communication is at the heart of medicine, certainly for patient care, but also in non-direct care specialties. By diluting the language here, patient care could certainly suffer, and the culture of medicine is weakened.
4.9 – systems-based practice requirements
I find it extremely concerning that authors opted to remove all specificity, then add in only one specific detail as a potential resource - artificial intelligence. Apparently, the ACGME feels its more important for residents to use AI than it is for them
- to understand how costs and finances shape care decisions of their patients and governments,
- to advocate for their patient's wishes and goals,
- to promote patient safety or disclose safety events,
- to coordinate care across the continuum of their specialty.
Once again, AI has made the cut for inclusion in the "common program REQUIREMENTS," while everything a patient might actually care about has been relegated to "GUIDANCE statements."
5.13.a. Faculty members no longer have specific evaluation requirements.
Removing the specificity here does indeed produce a shorter document. However, I can see no adequate reason not to leave it in place, and none was provided in the rationale document. Faculty should absolutely be evaluated on each of these criteria annually, at minimum.
The only change that makes sense here is to combine the wording "engagement with the educational program," which is vague, with the requirement for evaluation of "scholarly activity," to bring the section in line with prior decisions on what acceptable scholarly work is from section 4.18.
6.7. residents and faculty no longer have to tell patients/families which one they are.
This information is extremely salient for patients. As a patient, I deserve to know who is treating me, what role they play, and who is ultimately responsible for my care. I see no ethical or compelling reason to omit this section. Transparency builds trust, and the reverse is also true.
6.16c – programs no longer have to include efforts to enhance meaning found in work like by (protecting time with patients, providing admin support, promoting flexibility, enhancing professional relationships)
While I understand the difficulty in defining "meaning" since the concept varies by individual, removing this language, particularly without any documentation as to why, signals to me that the ACGME no longer even thinks it’s worth trying to create a supportive work environment. (or even pretending to try.) This is not morally permissible and goes against the stated mission of enhancing education quality for residents and fellows.
6.16e – removes requirement for understanding patient safety roles and abilities to report unsafe events
By removing this statement, I interpret the ACGME as intending to reduce the number of reported safety events. Perhaps this will benefit profit margins as root cause analyses may take time away from otherwise billable activities? Other than that, I can see no benefit to removing this statement. It appears to me that the mission of patient and public safety is no longer motivating this committee.
6.21 – removes specific details/requirements for resident mental health support
As has been the pattern in this rewrite, the loss of specificity outweighs any potential benefits of consolidation. Moving details about resident wellness, including substance abuse, depression, burnout, and other conditions that lead to tremendous amounts of both patient harm and physician suicides/deaths to the "guidance" document instead of leaving at as a "requirement" sends quite a message about how this committee views human life. (And a message that is antithetical to stated mission of the ACGME and of healthcare in general.)
6.22b – removes protection against negative consequences for requiring time away from work
The revision omits the key protection for residents against negative consequences for needing time away from work. Allowing retribution or bullying for self-care is a terrible precedent for any workplace, much less one where so much is at stake.
6.29 – maximum 80 hours/week on average over 4 weeks – includes clinical, educational, moonlighting
This is now, and has always been, a stupid way to do medicine. There are mountains of research to suggest that working more than 40-60 hours/week is unsafe - both for the patients and the residents. Further, it may contribute to a life-long pattern of poor work-life balance with devastating consequences.
In every American industry with regulated work hours, a 60-hour workweek is the max. That is not an average. It is counted continuously so that more than 60 hours are never worked in any 7-day period. And, I would argue that it is still too much, particularly when overwork becomes the norm and not the exception.
It is an open secret that residency programs require residents to log hours in patterns that match what they are required to report - a practice that causes moral distress and cognitive dissonance in addition to adding administrative burden to residents. I suggest that the ACGME require programs to automate this tracking both for ease of reporting and for accuracy. This should be feasible with current EMR technology. Further, work hour logs should be reviewed by an outside 3rd party.
An exhausted resident cannot learn effectively, nor can they provide their patients with their best. In fact, many other countries have managed to educate competent physicians without working them 2-4x as much as a normal worker, and achieve better care outcomes. The only logical reason I can give as to why we have persisted with this model is that residents are cheap, exploitable labor - and quite frankly, that is not a good enough reason to endanger their health or patients.
6.30 – mandatory 8 hours off between shifts is gone
This requirement must stay.
Humans require sleep. We perform our work better when we are rested. In fact, in the other regulated work-hour industries, 10 hours between shifts is a more usually minimum than 8, and removing this requirement altogether is a change in entirely the wrong direction. Especially considering that on some of these off-duty periods, residents will still be expected to take call from home.
Pilots are required to have 3 consecutive nights off when they travel far enough to be impacted by jet lag - that's not 72 hours of being on-call in an airport, it is true time AWAY from work. I suggest that physicians ought to have similar regulations to moderate the harms of shift work.
We know that changing shifts and/or working nights impairs alertness and cognitive function, increases stress, and causes increases in chronic illness. The ACGME has a duty to protect residents from as many of these harms as possible, and removing this sentence is a betrayal of that duty.
In the Rationale and Impact statement, it was mentioned that many programs are not receiving penalties for not complying with this standard - so the solution to that should be to penalize them. Removing the requirement altogether is the wrong choice, assuming the ACGME wishes to be logical and honors the existence of basic human rights. Sleep deprivation is a human right violation, and logic dictates that the best work is done by well-rested brains.
6.31 – after a 24-hour shift, must have 14 12 hours off
This proposed change is equally bizarre and unconscionable. I can think of no possible motive to reduce the number of required rest hours by 2 for residents other than to increase profits for hospitals, or perhaps test the waters in terms of pushback. Both are unacceptable. In other industries with regulated hours, there are much stronger protections for rest. For pilots (FAA), the minimum amount of rest is up to 72 hours in some circumstances. For drivers (DOT), they are required to spend 6-8 hours in their sleeping chamber, and that's after a 10-hour shift.
Firefighters, EMTs, police - they have all figured out better ways than us physicians at getting sleep and still meeting the 24/7 needs of their jobs. Reducing the amount of recovery after a 24-hour shift is not the way for medicine to catch up. It puts us further behind.
When resident physicians are often literally holding their patients’ lives in their hands, why would we want them to do that sleep-deprived?
In fact, given that a 24-hour shift is inherently disruptive to a natural sleep cycle, I believe that residents should have 48-72 hours off-duty following a shift like this. They need time to rest and reset their sleep cycles, so they can then resume patient care duties safely.
6.32 – must have 1 day (24 hours) off in 7, as averaged over 4 weeks.
In case you've forgotten, a normal weekend is 2 full days away from work in a row, and it happens every week. That means residents should have 14 days (48 hours) off duty every seven days.
One day off per week is simply not enough. There is no way to do laundry, clean a home, meal-prep, do uncompensated work (like taxes, resumes, etc), and have a nice outing with family/friends, manage caregiving responsibilities, nurture a romantic relationship, enjoy hobbies, connect with your community, and deeply rest all in 24 hours.
I have no idea what movies came out while I was in residency. I don't know what happened on the news, or what books were popular. Instead, I spent my little time off deciding if I wanted to have clean underwear or a clean floor or fresh groceries or a shower, because I knew I didn't have the energy to do all of it. Sometimes I skipped all of those things because I wanted to see a friend more instead. That is not work-life balance. A balanced life has room for all of those things and more.
Residents are humans. They are important workers. They need space to breathe, to exercise, to create, to connect, to play, to lay around and do nothing. They deserve that as much as any of their patients, as much as the housekeeping staff, as much as an auto worker does.
And, as it turns out, they can connect with their colleagues and patients and deliver better care when they are whole too. If you care about burnout, resilience, or self-care, you show it by protecting time away from work for residents. That's integrity.
6.33 – shifts must not exceed 24 hours of clinical work
Shift length should be no longer than 14 hours, perhaps up to 16 in very unusual circumstances. That would bring resident shift lengths more in line with shift lengths in every other industry, which makes sense because physicians are also human workers.
Perhaps it helps to think of it this way, would you want a loved one to be cared for by a resident on hour 23 at work? I couldn't remember a patient I met at hour 20 by the time I got to hour 23. I couldn't think about anything except trying to stay awake, and then about suicide. That experience is not unique.
Decision-making suffers after hours of being awake. Driving is impaired, to a degree comparable to being intoxicated. Asking physicians to make life-and-death decisions while impaired from fatigue is asinine. It is a great failing of our medical system, and of our society.
I am well-read on the history of work hour restrictions in medicine, as I would hope is the ACGME, and this one was absolutely written in blood. As physicians, we can keep doing better here, for ourselves, for our profession, for each other and our patients. This is one line of one document that has the power to save lives, reduce burnout, reduce physician suicide, and greatly improve the quality of patient care for millions. We don't have to wait for another very public death and lawsuit to modernize this regulation. We should not.
Let's move to a system of 10-hour shifts, and 4 of them per week. That way there is scheduled overlap that encourages handoff communication. It works for police, why not us?
6.33a – shifts can include an extra 4 hours of admin work after the 24 hours of clinical work (documentation, education, etc)
I believe a 24-hour shift is cruel. Extending it to a 28-hour shift is exceptionally cruel and unnecessary. No one should be allowed to work that many hours in a row. As a human, you must know that - but if not, I encourage you to stay awake and productive for this length of time this week and see how you feel, perhaps you can use the time to research how people respond to sleep deprivation and what conditions are optimal for high-stakes decision making.
In an extreme circumstance, perhaps related to an emergency (disease outbreak, natural disaster, act of god, etc), it is probably reasonable to extend a shift by 2 hours, but that's the limit. And those final 2 hours should be about communication and handoff only. No one is doing effective learning after being awake and working for 24 hours. The only thing that has the potential to matter more than sleep in that moment is safe patient care - which is better achieved by someone who has rested.