ACGME Work-Hour Restrictions: A Better Quality of Life, But at What Cost?

Since its development in 1981, the Accreditation Council for Graduate Medical Education (ACGME) has served as a non-profit, private coun­cil to monitor and evaluate resi­dent training programs across 133 disciplines in the United States. In 2003, the ACGME imple­mented codified work-hour restrictions, largely in response to a number of troubling factors including escalating resident work demands, increased public concern, the possibility of governmental intervention, and published research on the con­sequences of sleep deprivation. In doing so, it has significantly changed the face of orthopedic residency training programs.

As residents, I’m certain we have encountered varying levels of resis­tance to work-hour restrictions in our respective residency programs. At times, clinical conversation with attending surgeons has progressed to more peripheral topics like the ACGME restrictions. Speculation about the “shift-worker” mentality that these guidelines cultivate inevitable segues to broader questions about the rigors of current orthopedic training.

While there was a time when I might have eschewed this point of view, I have become more disconcerted with the paradigm shift in residency training. In response to a report on resident work hours from the Institute of Medicine (IOM), the ACGME released more stringent regulations in July 2011. Further discussions are underway to evaluate broadening the reductions to a possible 56-hour workweek. Current ACGME work-hour guidelines dictate that interns and junior residents can now only continuously work 16- and 24-hours shifts, respectively, and at least 8-10 hours must be allotted for rest before returning to duty. “Strategic napping” is “strongly encouraged” after 16-hours of duty; 80-hour limitations are mandated; and 1 in 7 days must be devoid of any clinical duties. In our hospital setting, interns can no longer take traditional 24-hour hospital call; limited coverage of the home-call pager is also not permitted, even with back-up assistance readily available.

In the interest of full-disclosure, I am a product of the contempo­rary work-hour restrictions and have never known the unregulated age of 48-hour shifts or weeks filled with q3 calls. However, as an intern and junior resident, I frequently exceeded my allotted work hours to complete my patient care duties and more importantly, operate post-call. I do not dispute that the ACGME work-hour regulations have improved qual­ity of life among residents.^1-3 I also believe that the majority of residents support the intentions of these guide­lines, but I have significant concerns about its downstream effects. There is limited evidence to support its questionable role in mitigating poor patient outcomes, in-house mortal­ity, or preventable medical error.⁴ Ultimately, my wider concerns lie in the compromise of our postgradu­ate training and what has aptly been referred to as “the erosion of medical professionalism.”⁵

As an intern, I once covered a Friday and Sunday call in late April for one of the junior residents who needed to go on emergency leave. With a chief resident available for backup, I had one of my busiest weekends of call to date, including 27 consults, 6 hip fractures, 5 open femoral and tibial shaft fractures, 3 comminuted elbows, and a C5 com­plete spinal cord injury. Exhausted from my attempts to manage this exclusively, I was struck by the value of this hard-nosed experience. That weekend, I learned the importance of preparation, calmness under pressure, prioritization, and ultimately, medi­cal decision-making. Given current constraints, this experience would be impossible, and in my opinion, ortho­pedic training suffers as a result of that lack of practical knowledge.

Compromised Training Experience. Increasingly, orthopedic faculty and program directors are concerned about the preparedness of their current train­ees and I believe this will only be exacerbated by more stringent work-hour restrictions such as those currently under debate.

In one recent study,⁶ only 17% of program directors believed that resi­dents were adequately prepared for clinical practice as an attending ortho­pedic surgeon, while 20% believed that residents had sufficient outpatient clinic exposure. In contrast, residents expressed contrary points of view, with 56% and 60% claiming sufficient prep­aration and clinical exposure, respec­tively. However, more recent data sug­gest worsening educational value with the increased work-hour restrictions imposed in 2011.⁷ In a national survey of US residents,⁷ nearly half of respon­dents believed that the new ACGME regulations negatively impacted prepa­ration for a more supervisory, senior resident role. More importantly, 41% of residents perceived a lower quality of resident education since implemen­tation of new work-hour restrictions.