The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 85, Issue 6

Topics in Training | June 01, 2003

Transition to the Eighty-Hour Resident Work Schedule

Allan M. Strongwater, MD

J Bone Joint Surg Am, 2003 Jun 01;85(6):1170-1172

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Comments (0)

text A A A

Extract

By now, just about everyone in the academic world has heard that the Accreditation Council for Graduate Medical Education (ACGME) will be imposing new standards for resident work hours that will take effect commencing with the resident class in July 2003 ¹ . Enforcement of the standard is the responsibility of the sponsoring institution, usually the medical school. However, monitoring compliance is the charge of the Resident Review Committee and failure of a residency program to comply with the guidelines may result in loss of Resident Review Committee accreditation.

Figures in this Article

Introduction

Introduction | References

In view of the multiplicity of roles served by the resident physician as student, worker, and educator, concern about complying with the new regulations while providing for educational and institutional needs has been expressed in a number of forums. In some municipalities, such as New York State, regulations regarding resident work hours have been enforced for several years ² . Additionally, the federal government has legislation (H.R. 3236) ³ pending on the subject. Although specific data associating medical errors with work hours are limited, and a report by the Institute of Medicine ⁴ has indicated that further study into the work-rest cycle is necessary, most people believe that regulation of work hours is warranted. Notwithstanding the type of work performed by medical personnel, there is substantial evidence in the literature to support the theory that work performance degrades with an inadequate work-rest cycle in other disciplines.

To assist in the transition from the current work schedules for residents to an eighty-hour work week, I explored two alternatives: a traditional call schedule and a night-float system. The first model is based on an every-fourth-night call ( Table I ) or an every-third-night call ( Table II ). The resident workday begins at 5:30 AM with morning rounds and ends at approximately 5:30 PM. This approach seems suited equally well for both large and small training programs. The ACGME requires that a resident, after being on call, have a work-free period of at least ten hours. This requirement effectively gives him or her a day that is free of all clinical responsibilities after being on call. During the month's schedule, the resident is off duty for eleven such days, six of which are regular weekdays. Given this rotation schedule, the weekly work hours vary from a low of sixty to a maximum of eighty-four hours, averaging seventy-five hours per week over a four-week period as permitted by the ACGME. Since the resident is working an average of seventy-five hours per week, there is sufficient flexibility to stay late occasionally for interesting cases or to assist with an unusually busy day. The proposed federal bill, H.R. 3236, will not permit averaging of time over multiple weeks; thus, this call schedule would not be in compliance with the federal guidelines, if enacted. The schedule is in compliance with all ACGME standards for a program with as few as two residents per year with a single additional resident in the research laboratory who can participate in the call schedule.

By comparison, increasing call to every third night ( Table II ) results in an average work time of seventy-eight hours per week. The resident is still unavailable eleven days of the month. However, the resident is now unavailable seven weekdays compared with six in the every-fourth-night rotation schedule. Although the resident is in house for an additional three hours per week on the every-third-night call schedule, he or she is less available during regular weekdays and there is less flexibility for the resident to stay late for interesting surgical cases. The every-third-night schedule has the potential to limit resident access to surgical cases and didactic instruction during weekdays. During either the every-third-night or every-fourth-night-call schedule, a backup call or second call taken from home is not included in the weekly hour count as long as the resident has a period of sufficient undisturbed rest and personal time.

The second model, referred to as a "night float," assigns a resident to be on duty during nighttime hours. Strictly speaking, this is not a call schedule but a defined resident rotation for a duration of several weeks to months. Throughout the week, residents work twelve-hour days from 6:30 AM until 6:30 PM and take call one weekend day. At the end of the workday, a resident on night float takes over the care of the orthopaedic service. The resident assigned to night float works Monday through Thursday, twelve hours per day, from 6:30 PM to 6:30 AM, as seen in Table III . On one of the weekend days, this resident works a twenty-four-hour shift. Four additional hours are included for turning over the clinical care to the day resident. The remaining two days, Friday and one weekend day, are covered by first-year residents in a traditional call rotation. Given this schedule, the night-float resident works an average of seventy-two hours per week. The night-float system works best with a minimum of three or four residents in each year of training because of the reduced daytime availability of the resident on night float. As in the traditional call model, the night-float system is in complete compliance with ACGME requirements and will comply with the proposed federal guidelines.

During discussions with various residents who worked in the two models, the majority preferred the traditional call schedule with the following day off. Residents in the night-float program noted that they became disoriented when they worked nights and had time off during the day. In both of the models, junior residents believed that there was an improvement in their working situation. Senior residents believed that more of the work fell to them because of the diminished availability of junior residents. A study that was based on a survey of 1000 general surgical residents in New York City demonstrated similar findings ⁵ .

In conclusion, reduced resident work hours are here to stay. Failure to comply with the ACGME guidelines can be devastating to a program. More frequent night call may actually reduce resident daytime availability. While the two models presented above may not be the only coverage schemes to meet the guidelines, they demonstrate that compliance, even in a program with a small number of residents, is possible.

View Larger

TABLE I: Every-Fourth-Night Call

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Hours
Call 24 hr	Off	Call 24 hr	Off	12 hr	Call 24 hr	Off	84
Call 24 hr	Off	12 hr	Call 24 hr	Off	12 hr	Off	72
Off	Call 24 hr	Off	12 hr	Call 24 hr	Off	Off	60
Off	12 hr	12 hr	12 hr	12 hr	12 hr	Call 24 hr	84
							Avg 75

Add to My JBJS

TABLE I: Every-Fourth-Night Call

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Hours
Call 24 hr	Off	Call 24 hr	Off	12 hr	Call 24 hr	Off	84
Call 24 hr	Off	12 hr	Call 24 hr	Off	12 hr	Off	72
Off	Call 24 hr	Off	12 hr	Call 24 hr	Off	Off	60
Off	12 hr	12 hr	12 hr	12 hr	12 hr	Call 24 hr	84
							Avg 75

View Larger

TABLE II: Every-Third-Night Call

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Hours
Off	Call 24 hr	Off	12 hr	Call 24 hr	Off	12 hr	72
Call 24 hr	Off	12 hr	Call 24 hr	Off	12 hr	Call 24 hr	96
Off	12 hr	Call 24 hr	Off	12 hr	Call 24 hr	Off	72
Off	Call 24 hr	Off	12 hr	Call 24 hr	Off	12 hr	72
							Avg 78

Add to My JBJS

TABLE II: Every-Third-Night Call

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Hours
Off	Call 24 hr	Off	12 hr	Call 24 hr	Off	12 hr	72
Call 24 hr	Off	12 hr	Call 24 hr	Off	12 hr	Call 24 hr	96
Off	12 hr	Call 24 hr	Off	12 hr	Call 24 hr	Off	72
Off	Call 24 hr	Off	12 hr	Call 24 hr	Off	12 hr	72
							Avg 78

View Larger

TABLE III: Night Float

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Hours
Long call 24 hr	Float 12 hr	Float 12 hr	Float 12 hr	Float 12 hr	Off	Off	72
Long call 24 hr	Float 12 hr	Float 12 hr	Float 12 hr	Float 12 hr	Off	Off	72
Long call 24 hr	Float 12 hr	Float 12 hr	Float 12 hr	Float 12 hr	Off	Off	72
Long call 24 hr	Float 12 hr	Float 12 hr	Float 12 hr	Float 12 hr	Off	Off	72
							Avg 72

Add to My JBJS

TABLE III: Night Float

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Hours
Long call 24 hr	Float 12 hr	Float 12 hr	Float 12 hr	Float 12 hr	Off	Off	72
Long call 24 hr	Float 12 hr	Float 12 hr	Float 12 hr	Float 12 hr	Off	Off	72
Long call 24 hr	Float 12 hr	Float 12 hr	Float 12 hr	Float 12 hr	Off	Off	72
Long call 24 hr	Float 12 hr	Float 12 hr	Float 12 hr	Float 12 hr	Off	Off	72
							Avg 72

References

Introduction | References

Accreditation Council for Graduate Medical Education. Common program requirements. For insertion into all specialty/subspecialty program requirements. .
http://www.acgme.org/dutyhours/dutyhourscommonpr.asp

New York State. New York State De-partment ofHealth Code, Section 405 (a.k.a. "Libby Zion Law"). .
http://www.toddwhitehurst.com/libbytxt.htm

H.R. 3236, 107th Cong., 1st Sess. (2001). Patient and Physician Safety and Protection Act of 2001. http://diariomedicovd.recoletos.es/profesion/hr3236.pdf.

Kohn LT, Corrigan JM, editors. To err is human: building a safer health system. Committee on Quality of Health Care in America, Institute of Medicine. Washington DC: National Academy Press; 1999.

WhangEE, Mello MM, Ashley SW,Zinner MJ. Implementing resident work hour limitations: lessons from the New York State experience. Ann Surg,2003;237: 449-55. 237449 2003 [PubMed]

Topics

medical residencies ; night time ; work schedule

First Page Preview

View Large

Username

Password

Access for Patients

Forgot Password?

Have a subscription to the print edition?

Not a Subscriber?

Buy this Article

Get online access for 30 days for $35

New to JBJS?

Subscribe to the online edition for 30 days for $75

Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.

Have a subscription to the print edition?

Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.

Activate your online account now

Forgot your password?

Enter your username and email address. We'll send you a reminder to the email address on record.

Username:*

Email Address:*

Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
by your institution, please contact you librarian or administrator for username and password information. Institutional
administrators, to reset your institution's master username or password, please contact subs@jbjs.org

References

Accreditation Statement

These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

CME Activities Associated with This Article

Submit a Comment

Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field

Comment Author(s) * (if multiple authors, separate names by comma)

Example: John Doe

Affiliation & Institution*

Comment Title*

Comment*

Cancel

Print
PDF
Email

Recipient(s) will receive an email with a link (good for 5 days) to 'Transition to the Eighty-Hour Resident Work Schedule'.
Your Name:*
Example: John Doe

Email Address:* CC Me:
Enter your valid email address. Example: jdoe@example.com

Recipient's Email Address:*

Separate multiple email address with semi-colons (up to 5).

Subject:* 's The Journal of Bone & Joint Surgery: 'Transition to the Eighty-Hour Resident Work Schedule'
Subject for your email.

Message:

(Optional, message will truncate at 1000 characters)

Processing your request... Please Wait...

Copyright © in the material you requested is held by The Journal of Bone & Joint Surgery, Inc. (unless otherwise noted). This email ability is provided as a courtesy, and by using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to Journal of Bone & Joint Surgery, Inc.'s Terms of Use. The information provided in order to email this topic will not be used to send unsolicited email, nor will it be furnished to third parties. Please refer to The Journal of Bone & Joint Surgery Inc.'s Privacy Policy for further information.

Copyright © The Journal of Bone & Joint Surgery Inc. All rights reserved.
Share
Get Citation

Allan M. Strongwater; Transition to the Eighty-Hour Resident Work Schedule. The Journal of Bone & Joint Surgery. 2003 Jun;85(6):1170-1172.

Download citation file:

RIS (Zotero)

EndNote

BibTex

Medlars

ProCite

RefWorks

Reference Manager

Copyright © The Journal of Bone and Joint Surgery, Inc.
Rights & Permissions
Article Alerts

Processing your request... Please Wait.
Submit a Comment