Dear Members of the Graduate Medical Education Community,
On behalf of the ACGME, its administration, Review Committees, and Board of Directors, I would like to wish you all a joyous, happy, and healthy New Year! As we embark on 2019, many challenges and opportunities face us, and I would like to bring a number of these to the forefront of our collective thought.
The first is to remind each of us that the third quarter of the academic year, beginning in January, is the second highest period of risk for resident and fellow suicide (see Yaghmour, et al. Academic Medicine, 2017.92:976-983), especially for those in their first year in a program. Our collective goal is the creation of a clinical learning environment focused on the well-being of all. Numerous resources are available on the ACGME website, including a resident suicide prevention video you might use to foster discussion in your programs. The National Academy of Medicine (NAM)’s Knowledge Hub is also an outstanding source of materials and tools for improvement of the well-being of our residents and fellows, faculty members, other professionals in the learning environment, and ultimately our patients. Please avail yourselves of these important resources.
As we start off the New Year, this letter is a reminder of the importance of creating a clinical learning environment that focuses on a culture of patient safety in residency and fellowship programs year round. An important component of creating that environment is compliance with the Maximum Hours of Clinical and Educational Work per Week requirement (Common Program Requirement VI.F.1.) that went into effect in July 2017. This ACGME Common Program Requirement states that “Clinical and educational work hours must be limited to no more than 80 hours per week, averaged over a four-week period, inclusive of all in-house clinical and educational activities, clinical work done from home, and all moonlighting. (Core)”
In 2016, the ACGME requested position statements on resident and fellow work hours from every specialty society and program directors association. Without exception, specialty societies affirmed their support for the 80-hour standard, when averaged over four weeks, while requesting greater flexibility for programs and residents and fellows within those maximum hours. The ACGME provided the requested increased flexibility, but emphasized that non-compliance from the 80-hour rule would not be tolerated. In other words, with increased flexibility as introduced into the Requirements, programs will need to account for the potential for residents and fellows to remain beyond their assigned work periods when developing schedules, to avoid exceeding the 80-hour maximum weekly limit, averaged over four weeks. This responsibility rests with the program and its Sponsoring Institution.
The ACGME Common Program Requirements’ new Background and Intent for this requirement provides direction to programs and Sponsoring Institutions in this regard. “Programs that regularly schedule residents to work 80 hours per week and still permit residents/fellows to remain beyond their scheduled work period are likely to exceed the 80-hour maximum, which would not be in substantial compliance with the requirement.(emphasis added) These programs should adjust schedules so that residents/fellows are scheduled to work fewer than 80 hours per week, which would allow residents/fellows to remain beyond their scheduled work period when needed without violating the 80-hour requirement. Programs may wish to consider using night float and/or making adjustments to the frequency of in-house call to ensure compliance with the 80-hour maximum weekly limit.”
As stated in the Background and Intent on oversight responsibilities: “The ACGME Review Committees will strictly monitor and enforce compliance with the 80-hour requirement. Where violations of the 80-hour requirement are identified, programs will be subject to citation and at risk for an adverse accreditation action.” In June 2018, the ACGME Board of Directors reaffirmed its strict interpretation of the 80-hour rule, and program compliance for the 2017-2018 academic year is now being assessed. Accordingly, Review Committees are now meeting and reviewing annual accreditation data based on these requirements, and will be issuing citations where violations of the 80-hour limit are identified.
Additionally, the new Common Program Requirements are explicit concerning other dimensions of the clinical learning environment, including harassment of residents or faculty members, whether related to patient care issues, to educational issues, or to reporting clinical work hour violations by residents and faculty members to the ACGME. The requirements recognize the significant risk of burnout and depression for physicians. They stress the need for both programs and institutions to prioritize physician well-being for faculty members as well as residents and fellows, ensuring protected time with patients and minimizing non-physician obligations. The specifications in these requirements reflect the ACGME's commitment to help physicians find meaning and joy in their work, while ensuring that programs and institutions provide the resources necessary for them to take care of themselves and their patients. For the first time, both programs and institutions, and their leadership, are responsible for prioritizing physician well-being, ensuring protected time with patients, minimizing non-physician obligations, ensuring an environment free of harassment and coercion, and providing residents and fellows with the opportunity to access medical and dental care.
Creating a clinical learning environment that fosters the best outcomes for our patients, and the well-being of our residents, fellows, and faculty members, is of utmost importance to the work we do at the ACGME. Implementing the updated requirements, demonstrating our commitment to both flexibility and well-being, and monitoring the impact the requirements have on graduate medical education outcomes, are only a few elements of a larger solution to achieve the type of environment that fosters the health and safety of our patients and our health care team.
We look forward to seeing many of you at the Annual Educational Conference from March 7-10, 2019.The conference will include a Fireside Chat between myself and 19th US Surgeon General Vivek H. Murthy, MD, MBA; a session with NAM President Dr. Victor Dzau, and Association of American Medical Colleges President and CEO Dr. Darrell Kirch, and me; and a number of sessions on well-being. Please join us in Orlando!
Thomas J. Nasca, MD, MACP
Chief Executive Officer
Accreditation Council for Graduate Medical Education (ACGME)