The history described below provides background of and context for the ACGME's legacy of attention to, and involvement in addressing the issue of long work hours during graduate medical education, and how these contribute to physician fatigue that might compromise patient safety.
Long hours are a component of medical residency and preparation for an occupation that requires hard work and dedication. Their origins, along with the term 'duty hours,' are found in traditional models of residency as brief periods of intense training, during which responsibility for patients rested with residents 24 hours a day, 7 days a week. By the late 20th Century, residency had become a multi-year experience that combines exposure to patients with new learning modalities in a vastly changed delivery system.
The effect of residents’ long hours on performance was initially studied in the early 1970s, and as early as 1980-1981, the ACGME Program Requirements for Graduate Medical Education in both Internal Medicine and Pediatrics included statements on a balance of education and service demands, and the “need for time for educational and personal pursuits.”
In February 1988, the recommendations of an ACGME Task Force on Resident Hours and Supervision specified standards for all accredited programs that included: 1) one day in seven away from the hospital; 2) on-call duty in the hospital no more frequently than every third night; 3) adequate backup if sudden and unexpected patient care needs create resident fatigue sufficient to jeopardize patient care; and 4) institutional policies to ensure that all residents are adequately supervised, with reliable methods of communication between residents and supervising physicians. The Task Force also recommended that each Review Committee develop specialty-specific standards regarding the frequency of duty and on-call assignments for residents.
In 1989, the Review Committee for Internal Medicine instituted an 80-hour weekly limit, averaged over four weeks, to become effective in July 1989, and by the early 1990s, six specialties, including internal medicine, the largest accredited specialty, had established a weekly duty hour limit.
In 1999, the Institute of Medicine (IOM) released, “To err is human: building a safer health system.” Although this report did not specifically implicate resident physicians or their long hours, its release prompted the ACGME Board of Directors and Strategic Initiatives Committee to explore sources of errors in the resident education environment, with reviews of the literature suggesting limits on resident hours and enhanced supervision as important strategies to promoting safety in teaching settings.
In September 2001, the ACGME authorized the formation of a Work Group on Resident Duty Hours and the Learning Environment, and charged it with the development of common standards for resident duty hours, and with providing recommendations in a number of related areas. The resulting common duty hour requirements, implemented in July 2003, represented a compromise between the need for specificity and the desire to allow some flexibility to benefit education and patient care. They allowed Review Committees like those for Emergency Medicine and Anesthesiology to maintain different requirements that accommodate patient care, safety, and education needs within the specialty. In 2003, with the threat of federal legislation to place a limit on resident hours, it was important to create common standards, while emphasizing that accreditation offers greater flexibility and sensitivity to specialty considerations than regulatory or legislative approaches.
In 2008, the common duty hour requirements instituted in 2003 had been in effect for five years, and the ACGME was prepared to explore refinements. Concurrently, the IOM announced that, at the request of elected officials and the Agency for Healthcare Quality and Research (AHRQ), it had convened an expert group to deliberate about resident hours and conditions to optimize patient safety.
The ACGME decided it would await the release of the IOM expert group report, and initiate a comprehensive, multifaceted process to develop new standards for duty hours, supervision, and professionalism. A key attribute of the approach would be an explicit commitment to provide all interested and affected stakeholders with the opportunity for input.
These updated standards were approved in 2010 for implementation in July 2011 and are available here [link "here" to 2011 DH Standards document-also linked under References and Resources]. The new standards were based on the conclusions of a 16-member Task Force on Quality Care and Professionalism. Over a two-year period this Task Force actively sought and elicited both professional and public input, including recommendations. The review process included:
- an International Symposium hosted by the ACGME
- written and verbal input from 140 medical organizations
- a commissioned review of the legal dimensions of resident duty hours oversight
- three separate external reviews of the medical and educational literature
- individual, in-person interviews with members of the IOM, sleep scientists, hospital executives, safety net institution leaders, patient safety experts, quality improvement experts, and, most importantly, patients and family members of patients harmed in the midst of receiving care in teaching institutions.
A 2013 article in the Annual Review of Medicine, co-authored by Drs. Ingrid Philibert, Thomas Nasca, and Timothy Brigham, and Ms. Jane Schapiro of the ACGME, addressed Duty Hour limits and patient care and resident outcomes. The article considers studies and data collected on duty hours and patient safety, highlights further areas for research, and makes recommendations for national policy to address the issue.