Report to Congress

IOM Proposes Additional Changes to Residents' Duty Hours, Workloads

By News Staff
12/17/2008

A recently released report from the Institute of Medicine, or IOM, recommends new restrictions on medical residents' duty hours and workloads, with the goals of minimizing fatigue and maximizing patient safety while maintaining "the rich educational experience necessary to achieve professional competence in the complexities of diagnosis and treatment of patients."

The recommendations in the IOM report, "Resident Duty Hours: Enhancing Sleep, Supervision and Safety," keep residents' work hours at the maximum of 80 hours per week -- averaged during a four-week period -- set by the Accreditation Council for Graduate Medical Education, or ACGME, in 2003. However, the report focuses on "increasing opportunities for sleep during residency training to prevent acute and chronic sleep deprivation and to minimize fatigue-related errors, rather than on simply reducing total duty hours."

One major change the IOM calls for is that shifts should not exceed 16 hours of continuous work. The current maximum shift length of 30 hours must be broken up after 16 hours by an uninterrupted five-hour sleep period between 10 p.m. and 8 a.m. The remainder of the shift should be spent only in transitional and educational activities, says the report.

In addition to the five-hour "protected sleep period," the recommendations propose

modifying the minimum time off between scheduled shifts from 10 hours after any shift to 10 hours after the day shift, 12 hours after the night shift, and 14 hours after any extended duty period of 30 hours;
setting a four-night maximum on in-hospital night shifts, with 48 hours off after three or four nights of consecutive duty;
increasing the number of days residents must have off each month from four to five, with one 48-hour period off per month; and
restricting moonlighting during residents' off hours, such that both internal and external moonlighting is counted against the 80-hour weekly limit. Currently, only internal moonlighting is factored into the 80-hour limit.

In addition to the changes in working hours, the recommendations call for greater supervision of residents by experienced physicians, limits on residents' patient caseloads and overlaps in residents' schedules during shift changes.

The report estimates that if the recommendations were implemented, the cost of shifting resident work to other clinicians, increased numbers of residents and support staff would be about $1.7 billion a year.

The report, which was requested by Congress in 2007, is based on extensive literature reviews and was compiled by the IOM's Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety. It was funded by HHS' Agency for Healthcare Research and Quality.

The ACGME is scheduled to meet in March to discuss the report's findings.

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