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Abstract
The Institute of Medicine’s Committee on Optimizing Graduate Medi-
cal Trainee (Resident) Hours and Work Schedules to Improve Patient Safety
evaluated the literature concerning (1) the impact of current residents’ duty
hours on patient safety and (2) the relationship of hours of work and sleep
to performance. The principal aim of residency training in the United States
is to prepare young doctors for the safe, independent practice of medicine
once they are on their own. While they are in training, residents are often
required to be on duty for long hours. Many medical educators believe that
extensive duty hours during training are essential to provide residents with
the rich educational experience necessary to achieve professional compe-
tence in the complexities of diagnosis and treatment of patients. In 2003 the
Accreditation Council for Graduate Medical Education (ACGME) adopted
common program requirements to restrict resident workweeks to an aver-
age of 80 hours over 4 weeks and the longest consecutive period of work
to 30 hours, as well as other limits.
Based on its review of the scientific evidence, the committee recognized
that it should focus on increasing opportunities for sleep during resident
training to prevent acute and chronic sleep deprivation and to minimize
fatigue-related errors, rather than on simply reducing total duty hours.
It recommends a protected sleep period of 5 hours during any work shift
beyond 16 hours duration. This on-duty sleep period should be counted
toward the weekly maximum of 80 hours averaged over 4 weeks. The
ACGME and residency programs should also
• increase the opportunity for sleep each day by having defined peri-
ods off between shifts,
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RESIDENT DUTY HOURS
• increase the number and regularity of days free from work for
“catch-up sleep” and recovery to minimize cumulative sleep loss,
• limit any additional paid healthcare work (moonlighting) that resi-
dents undertake, and
• provide safe transportation to any resident too fatigued to drive
home safely.
The committee sees benefits in continuing ACGME monitoring of
recommended duty hours because of the relationship of duty hours to edu-
cation. However stronger enforcement and whistle-blower processes need
to be adopted by ACGME and supported by outside oversight to promote
adherence and to protect residents who report pressure to violate rules.
Duty hour limits should be accompanied by specialty-specific workload
reductions and additional funding to avoid unintended consequences on
patient safety and residents’ safety and education. The committee recom-
mends improvements in the content of residents’ work, a patient workload
appropriate to learning and observation of duty hours, and better supervi-
sion with more frequent consultations between residents and their super-
visory attending physicians. Greater supervision, especially of first-year
residents, could intercept errors before they harm patients (e.g., having to
spend more days in a hospital because a resident did not order a diagnostic
test). Such “near-miss” experiences then become opportunities for learning.
In addition, residents should be trained in systems for quality improvement
and error reporting.
A handover, the transfer of patient information and responsibility for
patient care from one healthcare provider or team of caregivers to another,
is identified as a time when lack of clear communication can contribute
to error, but it can also be a time for learning and the interception of er-
rors. The committee recognizes that it is vital for residents to learn how to
perform handovers most effectively because handover frequency increased
after the 2003 duty hour limits and may increase further with new duty
hour parameters. Shift changeovers should be scheduled so that there is
adequate overlap time to conduct effective handovers.
To meet the committee’s recommendations, additional financial and
human resources will have to be obtained and existing ones applied dif-
ferently. Some resident work could be transferred to other clinicians, ad-
ditional residents, and support staff. According to an economic estimate of
select scenarios commissioned by the committee, the annual national costs
of personnel substitution could be around $1.7 billion. This represents ap-
proximately 0.4 percent of Medicare outlays. Additional funds for graduate
medical education (GME) would be needed to support recommendations
not contained in the economic model. The committee strongly urges Con-
gress and all potential GME and research funding sources to support the
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ABSTRACT
recommendations and the evaluations necessary to monitor and assess their
full effect. More knowledge of the details of implementation will help avoid
unintended consequences and refine duty hour and educational require-
ments over time.
Educating resident physicians is an exceedingly critical function of the
health system to ensure safe, high-quality health care to patients in the fu-
ture. A fundamental requirement of resident education is in-depth, firsthand
experience caring for actual patients. Ensuring the safety and well-being of
patients who participate in the education of residents is of utmost impor-
tance. One must look beyond hours of work alone as a risk factor and put
in place practices (e.g., time for sufficient sleep, enhanced supervision, ap-
propriate workload, unambiguous handovers) to minimize other contribu-
tors to errors so that the patient care environment can be made safer.
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