Position Statement

Limiting Residents’ Duty Hours

This Position Statement was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented and reach their own conclusions.

On July 1, 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented new duty standards that limit resident duty hours to a maximum of 80 hours a week as well as set other restrictions. These new standards affect all 7,800 residency programs in the United States, and those who fail to comply may face adverse action, including loss of accreditation. In addition, various states have adopted legislation or regulations that may differ from the ACGME standards.

The work environment of orthopaedic surgical residents is an area of major concern for the American Academy of Orthopaedic Surgeons (AAOS). The welfare of patients and the protection of a nurturing and effective training and educational experience for house staff are of paramount importance. Each residency program must ensure that the possible deleterious effects of resident fatigue do not compromise its educational objectives or safe and effective patient care. Studies should be encouraged and financially supported that clarify the effects of fatigue and continuity of care on resident education and safe patient management such that adjustments to duty hours and the work environment can be made in a rational and timely manner.

The American Academy of Orthopaedic Surgeons (AAOS) recognizes that residents are physicians in training and require an environment in which they achieve an education of the highest quality, while providing patients with safe and responsive care. Compliance with current ACGME duty hour standards and/or applicable state law is required.

At the completion of an orthopaedic surgical residency program, the AAOS believes that the orthopaedic resident must have acquired the knowledge and experience to care for patients with diverse musculoskeletal disorders and have developed those professional values and commitments necessary to sustain a career in orthopaedic surgery. The judgment and ability to recognize clinical patterns come from seeing and assisting in the management of a sufficient number of patients with musculoskeletal disorders. Providing residents with a thorough academic and clinical education must be balanced with the protection of residents’ well being and outstanding patient care.

The Fiscal Impact on Residency Programs

Although the ACGME has reduced the number of hours residents are allowed to be on duty, the amount of work and educational activities continue to grow. The availability of specialty physician services, often provided by residents, is an issue at many hospitals, particularly in many smaller community or urban hospitals. Many hospitals are struggling to make alternative arrangements for this coverage through the use of physician extenders, competing for funds dedicated to other programs and capital expenditures. The new ACGME rules will potentially add considerable costs for academic medical centers already struggling with decreasing third party payments and reductions in government reimbursement for services. Without additional funding to hire physician extenders to fill the void created by the duty hour limitations, academic medical centers will be restricted in their ability to fulfill many of their mandates, including provision of care for the uninsured and bringing new and improved medical technology to the clinical arena.

With significant nursing shortages looming, limitations on the number of residents, and falling reimbursement rates, residents are subject to pressures to do more work in less time and with less assistance. A reduction in resident labor that is unaccompanied by a significant increase in Graduate Medical Education (GME) funding from Medicare and/or third-party payers may produce several unfortunate and unintended results, including an increase in the number of errors from a lack of continuity of care. The medical community and the federal government need to think creatively about the use of current workforce and explore other options for increasing the healthcare workforce in order to preserve safe and high quality care.

The AAOS believes that preserving continuity of care and patient safety must be achieved within the framework of an educational environment that also respects the resident’s rest and quality of life. However, without adequate and appropriate staffing and financial support, teaching institutions will not be able to successfully address their educational mission as well as their obligation to provide quality patient care.

Further there is a growing body of evidence that medical errors have not decreased significantly since the implementation of the current work hour restrictions. The AAOS believes that any further decrease in resident work-hours, similar to those in place in Europe and Canada, needs to be thoroughly evaluated in light of its potential impact on resident education and patient care.

References

Biller CK, Antonacci AC, Pelletier S, Homel P, Spann C, Cunningham MJ, Eavey RD: The 80-hour work guidelines and resident survey perceptions of quality. J Surg Res 2006;135:275-281.

Bailit JL, Blanchard MH: The effect of house staff working hours on the quality of obstetric and gynecologic care. Obstet Gynecol 2004;103:613-616.

Byrnes MC, Narciso VC, Brantley L, Helmer SD, Smith RS: Impact of resident work-hour restrictions on trauma care. Am J Surg 2006;191:338-343.

December 2003 American Academy of Orthopaedic Surgeons.
Revised September 2008.

This material may not be modified without the express written permission of the American Academy of Orthopaedic Surgeons.

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