Coming off Interstate-280 in California, I rolled my windows all the way down and blasted a top 40 radio station at 2 a.m. I kept blinking to stop myself from drowsing off. At a red light, a horn jolted me awake. I had briefly dozed off behind the wheel.
I could not accurately count the hours I had been awake that week as a junior otolaryngology (head and neck) surgery resident in 2023. I was driving back and forth to cover calls at the local hospital, working upwards of 90 hours. That was technically in violation of rules limiting residents to 80-hour workweeks, but it was pretty normal for residents in procedural specialties. Luckily, other rules helped ensure that when I worked overtime, I could get rest before returning to the hospital.
Now, the organization overseeing medical residency programs — the Accreditation Council for Graduate Medical Education (ACGME) — has proposed weakening the rules that gave me some respite. The changes would eliminate the requirement for residents to have eight hours off between shifts, reduce the required time off after 24 hour in-house call in the hospital from 14 hours to 12, and eliminate the rule limiting in-house overnight call to no more than every third night.
The 80-hour workweek would remain. But the ACGME misses an important point: how those hours are distributed matters.
Any surgical resident can tell you that most programs do not truly follow an 80-hour workweek. They just underreport their hours to ensure the program does not get penalized. Work hour restrictions can’t stand up to the competing pressures of completing the necessary number of procedures to become a safe and competent surgeon while covering other patient care duties.
That makes the detailed protections that the ACGME is now trying to remove all the more significant. Since it is challenging to predict how many hours a resident will work in a given week, these ancillary rules about time off between shifts and frequency of call are concrete boundaries that chief residents, administrators, and program directors need to follow during scheduling.
One of the proposed changes would allow for 24-hour call every other night. The ACGME says this would be “nearly impossible” while complying with other rules but does not prohibit it. But “nearly impossible” is a challenge well accepted by hospitals trying to stretch limited resident labor with expanding coverage needs. Theoretically, a resident could be assigned three 24-hour call shifts in a week separated by only 12 hours off in between without violating an 80-hour workweek.
To understand why that matters, consider what 24 hours on call might look like.
In one of my first call shifts, I watched a child bleed to death from their mouth and nose from a swallowed foreign body that had punctured a major vessel. I evaluated 15 children with pediatric conditions ranging from healing after routine tonsillectomy to patients with cardiac anomalies and reconstructed airways. I assessed whether invasive fungal disease was spreading from a patient’s nose into their eye. I checked the health of patients who had portions of their leg used to reconstruct their face. I drained abscesses from the throat and helped anesthesiologists assess a patient with life-threatening airway swelling, among other tasks.
Imagine doing that three times in a row with only 12 hours in between to drive home, eat, change, shower, sleep, and drive back in time to do it all again. In addition, you would have to switch your circadian clock from working 6 a.m.-6 a.m. to 6 p.m.-6 p.m. for alternating 24-hour calls. Even if mathematically all of that can be done in less than 80 hours, the limited recovery time would be brutal.
The data are clear. Greater sleep impairment is correlated with increased physician burnout and self-reported medical errors. A study of residents taking 24-hour call shifts every third day found that response times deteriorated at the end of a call shift, and a cumulative deficit occurred with worsened neurobehavioral response performance on subsequent call shifts.
Not all of the proposed ACGME changes are going in the wrong direction. My intern year I worked for 21 days continuously on general surgery. When I asked about violating work hour rules, I was told that my weekends on either side of that 21 day stretch meant that averaged, I had technically received one day off every seven. The suggested ACGME rules fix this loophole, by stating that these minimum requirements have to be met during the same rotation.
That is why the ACGME should continue to strengthen meaningful protections for residents, not weaken them. Some late nights are inevitable — emergency operations, sick patients, and complicated care transitions are a fundamental part of training that should not be omitted.
That is precisely why it is important to create barriers between high intensity shifts with physical, intellectual, and emotional burden to avoid burnout.
The ACGME rules are not finalized. There is an open comment period until Oct. 22. Tell ACGME: We need to keep young physicians and surgeons awake.
Arifeen Rahman, M.D., is a clinical instructor in rhinology and endoscopic skull base surgery at the Medical University of South Carolina. She completed medical school and residency training at Stanford University.