Toward a New Paradigm in Graduate Medical Education in the United States: Elimination of the 24-Hour Call

Abstract

Sleep deprivation negatively affects resident performance, education, and safety. Concerns over these effects have prompted efforts to reduce resident hours. This article describes the design and implementation of a scheduling system with no continuous 24-hour calls. Aims included meeting Accreditation Council for Graduate Medical Education work hour requirements without increasing resident complement, maximizing continuity of learning and patient care, maintaining patient care quality, and acceptance by residents, faculty, and administration. Various coverage options were formulated and discussed. The final schedule was the product of consensus. After re-engineering the master rotation schedule, service-specific conversion of on-call schedules was initiated in July 2003 and completed in July 2004. Annual in-training and certifying examination performance, length of stay, patient mortalities, resident motor vehicle accidents/near misses, and resident satisfaction with the new scheduling system were tracked. Continuous 24-hour call has been eliminated from the program since July 2004, with the longest assigned shift being 14 hours. Residents have at least 1 free weekend per month, a 10-hour break between consecutive assigned duty hours, and a mandatory 4-hour "nap" break if assigned a night shift immediately following a day shift. Program-wide, duty hours average 66 hours per week for first-year residents, 63 hours per week for second-year residents, and 60 hours per week for third-year residents. Self-reported motor vehicle accidents and/or near misses of accidents significantly decreased (P < .001) and resident satisfaction increased (P = .42). The change was accomplished at no additional cost to the institution and with no adverse patient care or educational outcomes. Pediatric residency training with restriction to 14 consecutive duty hours is effective and well accepted by stakeholders. Five years later, the re-engineered schedule has become the new "normal" for our program.