The United States
In the United States, the Accreditation Council for Graduate Medical Education (ACGME) certifies resident education as a formal embodiment of professional self-regulation that answers to the profession and the public. In September 2010, the ACGME released new standards limiting duty hours for 111,000 residents and subspecialty fellows in 9,000 accredited programs.
These requirements, which came into effect in July 2011, include the following: a maximum of 80 duty hours per week (averaged over 4 weeks) a minimum of 1 day in 7 free of patient care responsibilities (averaged over 4 weeks) limitation of in-hospital call to no more than every third night (averaged over 4 weeks) a 10-hour period free of duty between duty periods a maximum of 4 additional hours for transitioning care for first-year post-graduate residents, a maximum shift length of 16 hours, irrespective of the setting (based on research showing increased errors for this group under extended duty periods) for intermediate-level residents, a 24-hour limit on continuous duty.
The standards also encompass key elements necessary for effective learning and safe patient care, including new standards for supervision, transitions of care, and preparing individuals for learning and practising in teams. The importance of ensuring the safety of patients in teaching settings has also resulted in the development of enhanced systems for monitoring the new standards, including on-site visits of programs and a new program under which each institution that sponsors residency programs will receive site visits every 18 months. The outcome of the newly developed ACGME standards is awaited and will be clear only in the years to come.
The defined goal must be a reduction in working hours for all doctors at all levels in the hospital services to a level sustainable for a healthy work–life balance for staff and safe care for patients. Tired, inexperienced, and poorly supervised junior doctors make more mistakes than both those who are more rested and adequately supervised, or more senior, and therefore knowledgeable and experienced, practitioners.
What is apparent at present is that there is no uniform formula or practice anywhere in the so-called “western” world. Europe has attempted to set statutory thresholds but has succeeded in applying these in fewer than 25% of member states so far. Only the Scandinavian countries have achieved systems of significantly reduced hours, often to fewer than 40 per week, without detriment to service delivery or to the education and training of young doctors.
The United Kingdom and several other European countries are close to achieving compliance with the 48-hour week, and thus more sensible resident duty hours, but most of the rest of Europe has a long way to go. North America and Australia are currently far in excess of this level and currently consider an 80-hours work week “safe.”
Even in Germany during the height of the bombing campaign by the RAF and the USAF in 1943 and 1944, which was aiming to paralyze the infrastructure of the Third Reich, the work week for aircraft production workers was increased to only 72 hours! In most health care systems, the correct adjustment of duty hours will be achieved only by a combination of sensible, agreed working practices coupled with service reorganization, which will inevitably mean fewer larger hospitals and enhanced community care and patient transport services. There is a long way to go in most countries before this goal can be reached.
I am grateful to Dr. Salvatore Spadafora, Vice Dean, Postgraduate Medical Education, University of Toronto, for providing information on the situation in Canada, to Dr. Ingrid Philibert, Senior Vice President, Field Activities, Accreditation Council for Graduate Medical Education, for information on the United States, and to Professor Nicholas J. Glasgow, Dean, Medicine and Health Sciences Medical School, The Australian National University, for information on Australia.
Resources and secretariat support for this project was provided by the Royal College.
This article has been published as part of BMC Medical Education Volume 14 Supplement 1, 2014: Resident duty hours across borders: an international perspective. The full contents of the supplement are available online at http://www.biomedcentral.com/bmcmededuc/supplements/14/S1. This article was submitted in 2011 and peer reviewed in 2012. Final acceptance for publication as part of this supplement was in 2014.
Publication of this supplement was supported and funded by the Royal College of Physicians and Surgeons of Canada. The funding agency played no role in the design, in the collection, analysis and interpretation of data; in the writing of the manuscripts; and in the decision to submit the manuscript for publication. The articles have been through the journal’s standard peer review process for supplements. The Supplement Editors declare that they have no competing interests.
The author declares he has no competing interests.
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