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Resident Work Hours and Patient Safety

Posted By Administration, Tuesday, September 20, 2016

Putting limits on the number of hours that physicians-in-training can work makes good sense—
for patients and for trainees.

By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi


Most people would agree that they do not perform at their best when tired.

For physicians in training, overwork and exhaustion has been shown to lead to motor vehicle accidents, needle sticks, burnout, and depression. It can also lead to medical errors and adverse events.

And yet, we are still debating work hour limits for resident physicians.

The Accreditation Council for Graduate Medical Education (ACGME) sets duty hour limits for physicians-in-training and this year conducted a planned five-year review of limits set back in 2011. For now, duty hour limits will remain at the current standard: first-year residents (interns) may work no more than 16 hours straight, while more senior residents may work up to 24 hours (and in some specialty areas, up to 28 hours). Other requirements include a maximum of 80 hours per week, averaged over a four-week period, and mandatory one day free of duty each week. Exceptions may be made on a case by case basis, for example, if a resident wishes to extend his or her hours to ensure continuity of care, but other patients must be appropriately handed off and the reasons for the extended hours must be documented.

A number of physician groups have lobbied to have duty hour standards relaxed, the argument being that shorter hours lead to more handoffs and a less comprehensive learning experience for trainees. ACGME granted waivers for residents participating in two research trials comparing outcomes between a group that followed the duty hour restrictions and another group that worked flexible, that is extended, hours. The FIRST trial found that outcomes were “no worse” with extended hours among surgical resident. The iCOMPARE trial, which looks at internal medicine residents, has yet to release results.

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Based on what we know, the National Patient Safety Foundation strongly advises maintaining duty hour limits for residents at all levels. In a statement given at the ACGME Congress on the Resident Learning and Working Environment held earlier this year, NPSF recommended that discussions of duty hours be held in the context of a drive to total systems safety; that residents be trained in effective handoff methods, such as I-PASS; and that meaningful measures of safety be applied in research on this issue. We should not have to choose between patient safety (that is, by limiting handoffs) and workforce safety (by increasing handoffs to allow residents sufficient rest) because, in fact, both are critically important, and we now have good methods available to ensure safe handoffs.


Recently the public has weighed in as well. A national poll conducted by Public Citizen, a nonprofit advocacy organization, found that 86% of respondents were opposed to lifting duty hour restrictions, and 80% support a 16-hour limit on all residents, not just first-year residents (interns).

Duty hours and patient safety are two of the areas that fall under the Clinical Learning Environment Review (CLER) program that ACGME announced earlier this year. The program was created to help “improve how clinical sites engage resident and fellow physicians in learning to provide safe, high quality patient care,” and among the first steps was to conduct site visits. The first program brief, released in July, shows that in the area of fatigue management and duty hours, many sites reported fatigue from volume of patients and increased fatigue among faculty.


The fact is that fatigue and burnout are serious issues among all members of the health care workforce that endanger both patients and health care workers. It will not be an easy issue on which to achieve consensus, but we must do better for those who care for the most vulnerable among us. We must see that they are afforded adequate rest and respite, while also receiving the training they need to deliver the highest quality care. This must be achievable—we need to creatively and rigorously determine how.

Do you agree that fatigue and burnout among health professionals is a problem? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.

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Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.

Tags:  medical education  workforce safety 

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