Betty Chang

The 2003 common duty hour limits: process, outcome, and lessons learned.

Long hours are a component of medical residency and a cultural symbol of a profession that requires hard work and dedication. The origins of residents’ long work hours, along with the term residency, are found in a traditional model of clinical education as a generally brief period of intense training, during which responsibility for patients rested with the residents 24 hours a day, 7 days a week. By the early 21st century, this has given way to a multiyear experience that combines participation in patient care with new learning modalities in a vastly changed delivery system. In the summer of 2002, the Accreditation Council for Graduate Medical Education (ACGME) granted preliminary approval to common duty hour limits for all specialties that became effective in July 2003. The establishment of common duty hour standards was prompted by 3 factors: a change in the delivery system, with increased patient acuity and demands on residents; a body of scientific knowledge showing negative effects of sleep loss on performance; and public attention on the number of hours worked by residents. In late 2001 this culminated in the introduction of legislation to limit resident hours and a petition to regulate duty hours as a workplace health hazard. In response, the ACGME charged a work group with the development of a blueprint for common duty hour limits. Setting duty hour standards across specialties was a watershed event for the ACGME, yet it built on 20 years of prior effort that had produced specialty-specific limits. The nuances of this approach made it difficult to explain its benefits to the public. The dialogue with the academic community and the public highlighted a gulf between these 2 stakeholder groups. From this emerged 2 concepts that served as guiding principles for the work group’s deliberations. The first was reaffirmation of the need for standards sensitive to the education and patient care needs of the 26 ACGMEaccredited specialties; the second was a need for the standards to reflect the science on sleep loss and performance. This led to a plan to develop common standards that would preserve an educational accreditation model that was flexible and sensitive to specialties, programs, and residents. At the same time, the standards should be easily explained to the public and viewed as comparable to the perceived safety and effectiveness of a legislative or regulatory approach.