Proposed revisions to medical resident schedule mandates would remove or reduce several limits on rest periods, overnight call, and night-float assignments while keeping the 80-hour average workweek rule.

The Accreditation Council for Graduate Medical Education (ACGME) proposal, released for public comment earlier this month, would eliminate the 8-hour rest requirement between shifts and shorten the mandatory time off after 24 hours of in-house call from 14 hours to 12 hours.

It would also remove the rule limiting in-house call to no more than every third night, averaged over 4 weeks, and the one governing night-float frequency. The new mandates would start from July 1, 2028.

The changes could be the most significant since ACGME instated the 80-hour average workweek for residents in 2003, and they have intensified long-running concerns about health and wellness protections for trainee physicians. At issue: will loosening restrictions on resident work hours improve training and patient care — or worsen fatigue, burnout, and patient safety?

“Why are we removing protections on a vulnerable group of people…in order to justify an ease of scheduling?” Naveena Daram, MD, who recently completed ob/gyn residency, asked in a public video. “Is this safer for the residents? Is this safer for patients?”

The updates are intended to provide programs with “greater flexibility in how they meet accreditation requirements while continuing to support high-quality education and patient safety,” an ACGME spokesperson told Medscape Medical News.

The proposed changes would reduce the number of Common Program Requirements by 43%, which the organization described in an impact statement as aligning with its commitment to reduce burden and minimize prescriptive requirements for training programs.

‘People’s Lives Are on the Line’

For Daniel Counihan, MD, a general surgery resident at Boston Medical Center in Boston, the 80-hour average workweek limit tells only part of the story.

He told Medscape Medical News that the way hours are scheduled matters “as much if not more” than the average weekly total.

Counihan, who has completed 2 years of residency and is now in his second research year, said his clinical schedule typically ranged from 5 to 21 consecutive days, with a mix of day and night shifts and weekly hours totaling up to 80 hours.

In his most demanding week, he logged more than 100 hours and several 24-hour call shifts. However, when averaged over 4 weeks, that intense workload remained within ACGME guidelines.

“What people tend to forget is that those 80 hours are not spent with breaks on our phones or talking with colleagues about out of work experiences,” Counihan said. “Those are 80 hours where people’s lives are on the line, with rarely an opportunity to eat a meal.”

Counihan, who is on the bargaining team of his resident’s union and involved in active contract negotiations, said the proposed changes could cut into an already limited recovery period. After 24-hour call, he said, signing out, commuting, showering, eating, and sleeping consume much of the time away from the hospital.

He worries the recommended changes, especially those targeting a reduction in rest periods, are the wrong solution for staffing and scheduling challenges.

“More residents is the solution, not the same number of residents who are more tired,” he added.

Even under the current rules, Counihan said he has fallen asleep at a computer while writing notes after a shift and had to take alternate transportation home when he didn’t trust himself to drive or ride his bicycle. He knows other residents who have fallen asleep at the wheel and totaled their cars.

“We should be aiming to make those stories less common, not more,” he said.

Programs Would Gain More Discretion

The proposed work-hour requirements would continue to set a maximum, not a minimum, ACGME noted in a “rationale and impact” statement.

It would also remove the ability of Review Committees to mandate specialty-specific requirements related to clinical and educational work hours and allow programs to assign fewer hours than the maximum if that “best serves resident education and patient care.”

For the in-house call frequency rule, the document said other retained limits made a separate standard less necessary.

The 80-hour average weekly maximum, 1 day free in 7, and the cap of 24 consecutive hours plus 4 hours for patient-safety activities make it “nearly impossible” for a program to assign residents in-house call more frequently than every third night on average, the document said. Monitoring compliance with that requirement “adds burden that is likely unnecessary.”

In an article outlining ACGME’s revision and feedback solicitation process, residents and fellows made up 7.5% of respondents in the first stakeholder survey and 13.1% of the second. Program directors and coordinators accounted for about half of respondents to each survey.

Stakeholder feedback showed strong support for keeping the 80-hour weekly limit, and support for greater flexibility was “often tied to concerns such as preserving continuity of patient care and better preparing residents for independent practice,” the article said.

Residents, Associations Weigh In

Daram questioned whether removing guidelines would improve residents’ learning. “We should be able to train competent, resilient physicians without constantly testing their levels of exhaustion and what their limits are,” she said.

Anesthesiologist Zackary Meade, MD, previously said in a video that removing the rules would take away the “one thing that some residents could have pointed toward” when challenging unsafe schedules. In a follow-up comment to Medscape Medical News, he said many residents already hesitate to push back.

“Reprisal is real, and it is quiet,” Meade said, who completed his residency this year.

Although giving programs more independence might help in some cases, he said it could leave residents carrying the burden if programs take advantage of the added flexibility.

The Committee of Interns and Residents (CIR), a union representing more than 40,000 residents and fellows, created a browser add-on to streamline public commenting. “ACGME is rewriting the rules of residency. Residents should have a say,” the site said.

A CIR spokesperson told Medscape Medical News that it created the tool to raise awareness and assist residents in navigating ACGME’s comment system. The add-on tool allows residents to draft and submit anonymous comments through ACGME’s official survey.

The Council of Residency Directors in Emergency Medicine is collecting feedback from members until October 1 to shape its response to the proposed rules. It also encouraged members to submit comments directly to ACGME by the October 22 deadline.

The experts cited in this article reported no relevant financial disclosures.

Steph Weber is an award-winning freelance journalist specializing in healthcare and law.