What are ACGME work hour rules?

[A_hominid]

I'm an FM PGY-2 and am trying to moonlight but don't know what the work hour rules are. I went to Wikipedia (btw, thank you very much for helping me get through college and med school. I know all the old farts are suffering MIs but it worked for me) and couldn't get an answer:

Starting in 2003, with revisions in 2011,[34] regulations from the Accreditation Council for Graduate Medical Education capped the work-week at 80 hours. Shifts are capped (with limited exceptions) at a maximum of 16 consecutive hours for a first year resident and 24 in the second and third years.[12][35][36][37]

The Accreditation Council for Graduate Medical Education (ACGME) has limited the number of work-hours to 80 hours weekly, overnight call frequency to no more than one in three, 30-hour maximum straight shifts, and at least 10 hours off between shifts. While these limits are voluntary, adherence has been mandated for accreditation.
from Wikipedia "Medical resident work hours"​

Well is it 24 or 30 hrs in a straight shift?? Figure I can get a quick answer here. Thanks guys.

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[Raryn]

I'm an FM PGY-2 and am trying to moonlight but don't know what the work hour rules are. I went to Wikipedia (btw, thank you very much for helping me get through college and med school. I know all the old farts are suffering MIs but it worked for me) and couldn't get an answer:

Starting in 2003, with revisions in 2011,[34] regulations from the Accreditation Council for Graduate Medical Education capped the work-week at 80 hours. Shifts are capped (with limited exceptions) at a maximum of 16 consecutive hours for a first year resident and 24 in the second and third years.[12][35][36][37]

The Accreditation Council for Graduate Medical Education (ACGME) has limited the number of work-hours to 80 hours weekly, overnight call frequency to no more than one in three, 30-hour maximum straight shifts, and at least 10 hours off between shifts. While these limits are voluntary, adherence has been mandated for accreditation.
from Wikipedia "Medical resident work hours"​

Well is it 24 or 30 hrs in a straight shift?? Figure I can get a quick answer here. Thanks guys.

Used to be 30 (24+6), lowered to 28 (24+4) a while ago. The last 4 are to wrap up prior work, "new" work cannot be done (i.e. they can make you do your notes/present patients/etc but can't assign you a new patient to see those last 4 hours)

The common program requirements are at: https://assets.fridgecms.com/81a7119e-968c-425c-b67c-1cc44e028d44/CPRs_Section VI_with-Background-and-Intent_2017-01.pdf

VI.F.3.a) Clinical and educational work periods for residents must not exceed 24 hours of continuous scheduled clinical assignments. (Core)

VI.F.3.a).(1) Up to four hours of additional time may be used for activities related to patient safety, such as providing effective transitions of care, and/or resident education. (Core)

VI.F.3.a).(1).(a) Additional patient care responsibilities must not be assigned to a resident during this time. (Core)

There's a variety of background explanation in that version of the requirements.

Your specialty may have more strict (but never less strict) versions of the same.

 

[A_hominid]

Thank you. PGY1 used to have more strict hour restrictions. That changed this year. So is there no distinction in work hour restrictions between PGY-1 and upper years now?

 

[Raryn]

Thank you. PGY1 used to have more strict hour restrictions. That changed this year. So is there no distinction in work hour restrictions between PGY-1 and upper years now?

There is no distinction in work hours between years now. The document I linked goes into the details of why. To quote:

Background and Intent: The Task Force examined the question of “consecutive time on task.” It examined the research supporting the current limit of 16 consecutive hours of time on task for PGY-1 residents; the range of often conflicting impacts of this requirement on patient safety, clinical care, and continuity of care by resident teams; and resident learning found in the literature. Finally, it heard a uniform request by the specialty societies, certifying boards, membership societies and organizations, and senior residents to repeal this requirement. It heard conflicting perspectives from resident unions, a medical student association, and a number of public advocacy groups, some arguing for continuation of the requirement, others arguing for extension of the requirement to all residents.

Of greatest concern to the Task Force were the observations of disruption of team care and patient care continuity brought about with residents beyond the PGY-1 level adhering to differing requirements. The graduate medical education community uniformly requested that the Task Force remove this requirement. The most frequently-cited reason for this request was the complete disruption of the team, separating the PGY-1 from supervisory faculty members and residents who were best able to judge the ability of the resident and customize the supervision of patient care for each PGY-1. Cited nearly as frequently was the separation of the PGY-1 from the team, delaying maturation of clinical skills, and threatening to create a “shift” mentality in disciplines where overnight availability to patients is essential in delivery of care.

The Task Force examined the impact of the request to consider 16-consecutive-hour limits for all residents, and rejected the proposition. It found that model incompatible with the actual practice of medicine and surgery in many specialties, excessively limiting in configuration of clinical services in many disciplines, and potentially disruptive of the inculcation of responsibility and professional commitment to altruism and placing the needs of patients above those of the physician.

After careful consideration of the information available, the testimony and position of all parties submitting information, and presentations to the Task Force, the Task Force removed the 16-hour-consecutive-time-on-task requirement for PGY-1 residents. It remains crucial that programs ensure that PGY-1 residents are supervised in compliance with the applicable Program Requirements, and that resident well-being is prioritized as described in Section VI.C. of these requirements.

 

[A_hominid]

LOL @ how senior residents and resident unions have different stances.

Just curious how do you know so much about this stuff? I looked this up before I posted here, found multiple PDFs on that website and was inundated with too many words. Most of the docs I work with aren't up to date on this stuff. All they can tell me is "back in my day..." Are you heavily involved in GME?

 

[LucidSplash]

I'm an FM PGY-2 and am trying to moonlight but don't know what the work hour rules are. I went to Wikipedia (btw, thank you very much for helping me get through college and med school. I know all the old farts are suffering MIs but it worked for me) and couldn't get an answer:

Starting in 2003, with revisions in 2011,[34] regulations from the Accreditation Council for Graduate Medical Education capped the work-week at 80 hours. Shifts are capped (with limited exceptions) at a maximum of 16 consecutive hours for a first year resident and 24 in the second and third years.[12][35][36][37]

The Accreditation Council for Graduate Medical Education (ACGME) has limited the number of work-hours to 80 hours weekly, overnight call frequency to no more than one in three, 30-hour maximum straight shifts, and at least 10 hours off between shifts. While these limits are voluntary, adherence has been mandated for accreditation.
from Wikipedia "Medical resident work hours"​

Well is it 24 or 30 hrs in a straight shift?? Figure I can get a quick answer here. Thanks guys.

But moonlighting is work outside of residency restrictions. The hours count toward the 80-hours on average rule but that’s it.

 

[A_hominid]

But moonlighting is work outside of residency restrictions. The hours count toward the 80-hours on average rule but that’s it.

Ohhh interesting. Good to know. Thanks.

 

[Raryn]

LOL @ how senior residents and resident unions have different stances.

Just curious how do you know so much about this stuff? I looked this up before I posted here, found multiple PDFs on that website and was inundated with too many words. Most of the docs I work with aren't up to date on this stuff. All they can tell me is "back in my day..." Are you heavily involved in GME?

Not particularly heavily involved with GME outside of being in training. I do have some specific interest in health policy and advocacy so I try to be well-read on this sort of thing, but haven't had any meaningful leadership positions related to the same since I graduated medical school. I've also been on SDN for 10 years and know where to find the answers to a lot of the common lines of questions.

Resident union positions are often in conflict with a significant number of residents. The people who are heavily involved enough in union politics to get leadership positions are often a different breed. Plus, residents are conflicted, I know plenty who are on both sides of the work hour debates.

As for the moonlighting rules, the FAQ that goes with the common program requirements explicitly has this to say:

The hours spent moonlighting are counted toward the total hours worked for the week. No other clinical and educational work hour requirements apply, but the following requirements do:
VI.F.5.a) “Moonlighting must not interfere with the ability of the resident to achieve the goals and objectives of the educational program, and must not interfere with the resident’s fitness for work nor compromise patient safety.”

VI.B.3.-VI.B.4.c).(2) “The program director, in partnership with the Sponsoring Institution, must provide a culture of professionalism that supports patient safety and personal responsibility. Residents and faculty members must demonstrate an understanding of their personal role in the: provision of patient- and family-centered care; safety and welfare of patients entrusted to their care, including the ability to report unsafe conditions and adverse events; assurance of their fitness for work, including: management of their time before, during, and after clinical assignments; and, recognition of impairment, including from illness, fatigue, and substance use, in themselves, their peers, and other members of the health care team.”

Your program can also institute any other requirements/limits on moonlighting that it wants.

 

[ThoracicGuy]

There is no distinction in work hours between years now. The document I linked goes into the details of why. To quote:

So PGY 3, 4, or 5s are held by the same hours now? So what happens when people get into the real world and find out they have work that lasts more than 24+4 hours?

 

[Raryn]

So PGY 3, 4, or 5s are held by the same hours now? So what happens when people get into the real world and find out they have work that lasts more than 24+4 hours?

Officially, PGY 2-N have always been held by the maximum (originally 24+6, now 24+4). That never changed. No matter if you're a PGY 10 neurosurgical fellow or what.

 

[ThoracicGuy]

Officially, PGY 2-N have always been held by the maximum (originally 24+6, now 24+4). That never changed. No matter if you're a PGY 10 neurosurgical fellow or what.

It just seems that they are doing more and more coddling of residents these days. I don't think we should go back to pre-80 hours. I did that and the 80 hours was a nice improvement, but whittling it down more and more will make the shock of being an attending that much harder. I worry that it'll cause people to be less willing to do what needs to be done for their patients when they are out because their hours are up and they need to sleep or whatever.

 

[Raryn]

It just seems that they are doing more and more coddling of residents these days. I don't think we should go back to pre-80 hours. I did that and the 80 hours was a nice improvement, but whittling it down more and more will make the shock of being an attending that much harder. I worry that it'll cause people to be less willing to do what needs to be done for their patients when they are out because their hours are up and they need to sleep or whatever.

The current rules seem perfectly reasonable - the old (pre-2003) system of allowing something like a 36 hour shift followed by 12 hours out of the hospital and back in work the next day is untenable. The rules are more flexible than they were even last year, and I think 28 hours, one day off in 7, and 80 hours averaged over 4 weeks is a decent enough maximum allowable framework. The 30 hour cap has applied to all residents since at least 2003, and it has been 28 hours since what, 2012? No one really made a big fuss over that change (as compared to the intern changes)

Very few attendings in any field will ever take in house call for >24 hours. Maybe rural EM or a trauma surgeon at a level 1 center. That said, some surgeons who do emergency cases might have a full day of cases, an emergent case overnight, and then have a full day scheduled the next day, but even that is the exception rather than the rule for the vast majority of us.

Of course, I might be biased. I just signed for an attending job with 36 hours of patient facing contact weekly and no inpatient coverage.

 

[rokshana]

LOL @ how senior residents and resident unions have different stances.

Just curious how do you know so much about this stuff? I looked this up before I posted here, found multiple PDFs on that website and was inundated with too many words. Most of the docs I work with aren't up to date on this stuff. All they can tell me is "back in my day..." Are you heavily involved in GME?

you need to know these things and you read up on it...the info really isn't that hard to find.

 

[rokshana]

So PGY 3, 4, or 5s are held by the same hours now? So what happens when people get into the real world and find out they have work that lasts more than 24+4 hours?

the work hours have always been the same for PGYs >1...however they are basically in for a rude awakening when they find out that ACGME work hour and caps don't apply to attendings...

 

[rokshana]

The current rules seem perfectly reasonable - the old (pre-2003) system of allowing something like a 36 hour shift followed by 12 hours out of the hospital and back in work the next day is untenable. The rules are more flexible than they were even last year, and I think 28 hours, one day off in 7, and 80 hours averaged over 4 weeks is a decent enough maximum allowable framework. The 30 hour cap has applied to all residents since at least 2003, and it has been 28 hours since what, 2012? No one really made a big fuss over that change (as compared to the intern changes)

Very few attendings in any field will ever take in house call for >24 hours. Maybe rural EM or a trauma surgeon at a level 1 center. That said, some surgeons who do emergency cases might have a full day of cases, an emergent case overnight, and then have a full day scheduled the next day, but even that is the exception rather than the rule for the vast majority of us.

Of course, I might be biased. I just signed for an attending job with 36 hours of patient facing contact weekly and no inpatient coverage.

its the hours of non patient facing administrative work that will get you...hopefully your new place has a good EMR...

 

[ThoracicGuy]

the work hours have always been the same for PGYs >1...however they are basically in for a rude awakening when they find out that ACGME work hour and caps don't apply to attendings...

24+4 is new though...

 

[rokshana]

24+4 is new though...

true, that was instituted in 2012 with the 16 hour work day for interns...but all PGYs > 1 have the 24 + 4 instead of 24+ 6...which basically made people have to do the same amount of work in less time.

 

[Raryn]

24+4 is new though...

It was 24+6 way back in 2003. Not that different.

 

[ThoracicGuy]

It was 24+6 way back in 2003. Not that different.

What's next? 24+2?

Maybe these kids should get off my lawn too.

 

[rokshana]

It was 24+6 way back in 2003. Not that different.

that's when the 80 hr work week went into effect, right?

 

[Raryn]

that's when the 80 hr work week went into effect, right?

Yes.

These are the original rules (as of 2003):

1.Residents are limited to a maximum of 80 duty hours per week, including in-house call, averaged over four weeks. In certain cases, starting in July 2004, residency programs will be allowed to increase duty hours by 10 percent if doing so is necessary for optimal resident education and the program receives approval from the appropriate RRC.

2.Residents must be given one day out of seven free from all clinical and educational responsibilities, averaged over four weeks.

3.Residents cannot be scheduled for in-house call more than once every three nights, averaged over four weeks.

4.Duty periods cannot last for more than 24 hours, although residents may remain on duty for six additional hours to transfer patients, maintain continuity of care or participate in educational activities.

5.Residents should be given at least 10 hours for rest and personal activities between daily duty periods and after in-house call.

6.In-house moonlight counts toward the weekly limit. In addition, program directors must ensure that external and internal moonlighting does not interfere with the resident's achievement of the program's educational goals and objectives.

 

[mvenus929]

In addition to the 80 hour workweek, the 24+4 shifts, and 1 day off in 7 (averaged over 4 weeks or a block), there are mandatory time off requirements. You must have 8 hours between shifts (preferrably 10), and 14 hours off after a shift lasting 24+ hours.

 

[Raryn]

In addition to the 80 hour workweek, the 24+4 shifts, and 1 day off in 7 (averaged over 4 weeks or a block), there are mandatory time off requirements. You must have 8 hours between shifts (preferrably 10), and 14 hours off after a shift lasting 24+ hours.

They got rid of the "must have 8" and "preferably 10" last year. It's now "preferably 8".

VI.F.2.b) Residents should have eight hours off between scheduled clinical work and education periods. (Detail)

VI.F.2.b).(1) There may be circumstances when residents choose to stay to care for their patients or return to the hospital with fewer than eight hours free of clinical experience and education. This must occur within the context of the 80- hour and the one-day-off-in-seven requirements. (Detail)

The "must have 14" rule still exists.

VI.F.2.c) Residents must have at least 14 hours free of clinical work and education after 24 hours of in-house call. (Core)

 

[michaelrack]

I finished residency in 2002, and disagree with the 80 hour limit and other limits...that said, I don't know as any attendings who work 24 hours+ shifts (although I don't know many surgeons).... unless I am at the gym, I am always in bed by 1 am

 

[mvenus929]

I finished residency in 2002, and disagree with the 80 hour limit and other limits...that said, I don't know as any attendings who work 24 hours+ shifts (although I don't know many surgeons).... unless I am at the gym, I am always in bed by 1 am

I work 24 hour shifts (as an attending). Several of my attendings in residency worked 30-36 hour shifts (rounds one day, in house call overnight, complete day the following day).

 

[Winged Scapula]

The current rules seem perfectly reasonable - the old (pre-2003) system of allowing something like a 36 hour shift followed by 12 hours out of the hospital and back in work the next day is untenable. The rules are more flexible than they were even last year, and I think 28 hours, one day off in 7, and 80 hours averaged over 4 weeks is a decent enough maximum allowable framework. The 30 hour cap has applied to all residents since at least 2003, and it has been 28 hours since what, 2012? No one really made a big fuss over that change (as compared to the intern changes)

Very few attendings in any field will ever take in house call for >24 hours. Maybe rural EM or a trauma surgeon at a level 1 center. That said, some surgeons who do emergency cases might have a full day of cases, an emergent case overnight, and then have a full day scheduled the next day, but even that is the exception rather than the rule for the vast majority of us.

Of course, I might be biased. I just signed for an attending job with 36 hours of patient facing contact weekly and no inpatient coverage.

Prior to 2003, outside of New York, there were no requirements/restrictions.

The problem with Q2 call? You miss half of the good cases!

But I agree, it was indefensible.

 

[michaelrack]

I work 24 hour shifts (as an attending). Several of my attendings in residency worked 30-36 hour shifts (rounds one day, in house call overnight, complete day the following day).

Were they generally sleeping during the in house call? I do busy weekends covering psych wards in which I stay in a very close hotel, I get a lot of calls but only rarely have to go in the middle of the night... I should have clarified in my post that I was talking about private practice and non academic positions . ...

 

[ryerica22]

I think some of these rules make things harder for residents in the longrun.

 

[mvenus929]

Were they generally sleeping during the in house call? I do busy weekends covering psych wards in which I stay in a very close hotel, I get a lot of calls but only rarely have to go in the middle of the night... I should have clarified in my post that I was talking about private practice and non academic positions . ...

Technically, my clinical job is non-academic. I don't supervise residents, and paid by a private group. I'm contracted for a certain number of shifts each month, and can volunteer to work more on top of that for additional pay. And often times, I am the only attending outside of the ED in house. Most of the time I'm able to sleep--I've traditionally had a white cloud. My friend, however, has only slept a significant amount of time once (we've been doing this for 7 months now). Similar situation to our interns staying for 24 hours on Saturdays--most times, they can get a few hours of sleep. Sometimes, the patients want to keep acting up and they aren't able to get any.

Our attendings maybe got some sleep--there's usually a slump in the NICU between 1a-4a that you can sleep. But sometimes sick babies are sick and want to code and try to die on you all night.

Either way, those positions do exist still, and I'd argue that it's not good to experience that sort of thing for the first time when you're by yourself.