Understanding accreditation council for graduate medical education (ACGME) guidelines: resident and program director interpretation of work-hour restrictions

Abstract

Purpose: All residency programs must comply with the Accreditation Council for Graduate Medical Education (ACGME) work-hour guidelines, but compliance requires accurate interpretation of the rules. We previously surveyed the residents and program directors of general surgery residency programs and found significant discordance between what program directors and residents considered violations. Our current study expands our research to include family medicine and emergency medicine residents and program directors. This study aims to identify discrepancies of work-hour guideline interpretation within and between the specialties.

Methods: We created 10 scenarios related to work-hour issues. The ACGME reviewed them and judged whether a violation occurred in each scenario. From these scenarios, an Internet-based survey was generated and distributed electronically to every family medicine and emergency medicine residency in the United States. (Surgery programs were previously surveyed from March 1 through May 21, 2007 with the same scenarios.) Responses were collected anonymously via our Internet-based survey database from March 1 through May 17, 2008. All respondents were asked to identify themselves as either a program director or a resident. After reading each scenario, participants were asked to answer either "yes," "no," or "maybe/not sure." The option of "maybe/not sure" was in place to discourage guessing; those responses were not included in our analysis. After the data were collected, we calculated the percent of respondents that answered "yes" or "no" for each of the 10 scenarios related to work-hour issues. The results from within specialties (program directors vs residents) and between specialties (general surgery, family medicine, emergency medicine) were compared.

Results: There were a total of 883 respondents (334 general surgery, 374 family medicine, and 175 emergency medicine). Respondents identified themselves as program directors (97), assistant program directors (21), or residents (765). Statistically significant differences were identified in the responses of program directors and residents within and between specialties.

Conclusions: Based on the scenarios we presented, there was a difference in interpretation between residents and program directors. There was even disagreement among program directors of different specialties on the interpretation of some of the scenarios. This finding reveals an ambiguity in the work-hour restrictions. We conclude that the ACGME-mandated work-hour guidelines are confusing and not universally understood. This problem is compounded by the cross-training with "off-service" residents from other specialties such as family medicine and emergency medicine. Hence, enforcement of the work-hour restrictions may be problematic, despite the best intentions and sincere effort of directors and residents to interpret the rules.