Physicians have until October 22, 2026, to weigh in on proposed Accreditation Council for Graduate Medical Education (ACGME) changes that would threaten longstanding intern, resident, and fellow work-hour safeguards.
The stated ACGME goal is greater flexibility. The question is: flexibility for whom?
Released on September 8 as part of a major revision to the Common Program Requirements for Residency, the proposal would:
- Eliminate the 8-hour rest recommendation between shifts completely (§6.30).
- Eliminate the protection that prevents residents from being scheduled for in-house call more frequently than every third night (§6.38).
- Eliminate specialty review committees’ authority to set additional limits on night float, including its length and frequency (§6.37).
- Reduce required time off after 24-hour in-house call from 14 hours to 12 (§6.31).
The ACGME Task Force argues that the 80-hour workweek, one-day-off-in-seven requirement averaged over a 28-day period, and limits on continuous duty make several existing safeguards redundant. Removing those rules, it contends, would reduce scheduling and administrative burdens.
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The 80-hour average attempts to limit total work, but it cannot substitute for protected recovery time. Even when honored, it can still leave residents dangerously fatigued and inadequately protected.
Yes, continuity of care matters. Handoffs carry risks, and in rare, extenuating circumstances, remaining with a patient may be both clinically important and educationally valuable. But an occasional decision to violate duty hours for an exceptional clinical need is fundamentally different from giving programs routine authority to schedule trainees with inadequate recovery time.
We argue that weakening any one duty-hour safeguard threatens the integrity of the entire duty-hour framework, risking a gradual erosion of protections that took decades to establish. There are several explicit arguments as to why increased “flexibility” is a dangerous guise for trainee exploitation.
1. Trainees already work more hours than they report
The case for removing safeguards depends on confidence that the remaining limits will hold. Yet duty-hour reporting already misses violations.
In a national survey published in 2013, 62.1 percent of responding surgical residents reported falsifying duty-hour records. Likewise, a 2019 study at one pediatric residency program found more violations using electronic health record data than resident self-reports in 36.8 percent of resident rotation blocks. These studies raise a consistent concern: Recorded compliance can conceal excessive work.
One of us experienced this pressure firsthand during residency. Honestly reporting a 90-hour workweek instead of logging 80 meant multiple additional meetings with program leadership. The resident who reported the excessive hours became the problem. Those meetings consumed time already needed for sleep and recovery. Entering 80 hours was simply easier than documenting what had actually happened, and bearing the consequences.
A reporting system that makes honesty more burdensome than falsification creates an incentive to conceal the very problem it is supposed to identify. An ideal response to this dilemma is to add protection for residents who report duty-hour violations. Instead, the ACGME proposes removal of safeguards that help to prevent excessive workloads in the first place.
For this reason, any threat to other duty-hour policies is inherently a threat to the 80-hour weekly work limit.
2. Trainees must help define the flexibility they need
The ACGME sought stakeholder feedback, and trainees did participate, but they made up a minority of respondents. Residents and fellows represented just 13.1 percent of respondents to the survey addressing work hours, while program leadership and coordinators together accounted for approximately 50 percent of respondents, the latter of whom have never undergone medical training. Of 94 groups responding to a separate focused-feedback survey, only one was classified as a resident organization.
These figures establish that trainees (whose daily working conditions, well-being, and education are directly at stake) have not been centered as primary stakeholders. With trainees outnumbered 4:1 by program leadership alone, and by an even wider margin once administrative roles are included, these numbers cannot reasonably be interpreted as trainee endorsement. The ACGME has yet to demonstrate how trainee perspectives meaningfully shaped these proposals. Moving forward, the ACGME should engage directly with established trainee organizations, including the Committee of Interns and Residents, the nation’s largest house-staff union, and resident and fellow sections of major organized medical societies. A balanced discussion of flexibility should examine the choices trainees want to have, as well as the scheduling constraints programs want removed.
Furthermore, an open comment period cannot eliminate the pressures of the medical hierarchy. Trainees seeking a chief residency, fellowship, or faculty position may reasonably worry about the downstream implications of their comments. We cannot count how many remain silent, but we should not interpret silence as agreement.
3. Trainee safety should not depend on institutional goodwill
The proposed changes would grant institutions greater scheduling latitude without giving trainees corresponding leverage. Internship, residency, and fellowship are not ordinary employment relationships: Programs control schedules, evaluations, and career advancement. If training negatively impacts well-being, transferring is extraordinarily difficult, if not impossible. It is rare in modern society to find employees who cannot negotiate individual contracts and cannot leave their jobs without jeopardizing their careers. ACGME work-hour rules serve as their sole regulatory defense.
One of us saw these competing interests when a program used jeopardy coverage, meant solely for trainee unanticipated illness, to absorb rising hospital patient volume instead of hiring additional attendings or advanced practice providers. The hospital met its staffing needs by drawing on resident labor, leaving trainees to absorb novel uses of back-up schedules without sufficient power to negotiate the extra burden. This experience illustrates a key incentive the proposals fail to adequately address: Assigning more work to trainees is often cheaper and easier than expanding institutional staffing.
While program leaders often care deeply about well-being, they face relentless pressure to maintain clinical coverage. National standards must account for these operational pressures, especially when budget constraints tempt systems to stretch the limits of a captive workforce.
A trainee’s access to protected rest must never depend on where they match or how sympathetic their local leadership happens to be. Baseline protections must function as a permanent regulatory floor, a non-negotiable standard that accrediting bodies can strengthen, but never erode. Reversing established safeguards sets a dangerous precedent that administrative convenience can override physician health and patient safety.
Slashed recovery time after a 24-hour-plus shift (from 14 hours down to 12) makes this tradeoff concrete. Twelve hours away from the hospital is not twelve hours of sleep: Commuting, meals, childcare, lactation, and caregiving responsibilities all compete for that time. Programs gain greater scheduling flexibility; residents lose the protected time required to recover safely and return ready to care for patients. Stripping away long-standing protections will erase decades of hard-won progress for trainee rights in a single stroke.
True flexibility that benefits trainees would look different: Giving trainees meaningful input into their own schedules, reliable relief when too fatigued to work safely, and the ability to report unsafe conditions without jeopardizing their training would be good places to start. Changes that genuinely support trainee education and well-being require adequate institutional staffing, strict accountability, and clear, irreducible national minimum standards.
Resident work-hour protections are under fire, and trainees should not have to defend them alone. Before October 22, attending physicians and organized medicine must join them in demanding that these safeguards remain intact. We cannot let decades of progress go up in flames in the name of “flexibility.”
Dayna Isaacs is a hematology/oncology fellow physician at UC Davis Health in Sacramento, California. Her expertise spans health policy, public health, advocacy, and street medicine, and she is committed to partnering with historically marginalized patient populations.
She is a trustee of the California Medical Association and a delegate to the American Medical Association, sponsored by the American Society of Clinical Oncology. She formerly served as a regional vice president of the Committee of Interns and Residents. She is pursuing a master’s degree in clinical research at UC Davis, with research interests in expanding access to cancer treatment and addressing the social determinants of health.
Shireen Saxena is a combined internal medicine and pediatrics resident in Los Angeles, California, and a regional vice president of the Committee of Interns and Residents (CIR/SEIU).
