Comments Regarding the Proposed Major Revision of the Accreditation Council for Graduate Medical Education’s Common Program Requirements (Residency)

By Nina Zeldes, Ph.D.

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Public Citizen, a national nonprofit consumer advocacy organization with over one million members and supporters nationwide, submits the following comments on the proposed major revision of the Accreditation Council for Graduate Medical Education’s (ACGME’s) common program requirements (residency). The proposed changes are anticipated to go into effect in July 2028.

In the United States the ACGME is solely responsible for accrediting residency programs and for monitoring compliance with the council’s work-hour standards. The ACGME has a great responsibility for the well-being and safety of resident physicians and the safety of the patients in their care.

However, when the ACGME limited work hours for all resident physicians in 2003 and again in 2011, the council limited hours to a lesser extent than recommended by expert panels.[1] In 2017, when the ACGME last implemented work-hour standards, some of the prior work-hour protections were rolled back (see Table).

Public Citizen’s Health Research Group is concerned that the proposed revisions would further erode workplace safety for resident physicians. Several of the planned changes roll back essential protections (such as the required rest time between shifts) without which resident physicians as well as the patients in their care may be harmed. Moreover, by failing to provide guidance on several key work-hour requirements, the proposed revisions may facilitate the scheduling of excessive work hours for resident physicians. The ability to enforce work-hour standards will be diminished. Moreover, reporting violations will be impossible in instances where there are no longer criteria for what a violation is.

Table. Key ACGME Work-Hour Requirements in 2011, 2017, and 2028, and Public Citizen’s Recommendations

	2011 ACGME Work-Hour Requirements	2017 ACGME Work-Hour Requirements	2028 Proposed ACGME Work -Hour Requirements	Public Citizen’s Recommendation
Maximum hours of work per week	80 hours, up to 88 hours for some specialties (averaged over four weeks)	80 hours, up to 88 hours for some specialties (averaged over four weeks)	80 hours (averaged over four weeks)	80 hours per week, no averaging
Maximum in-hospital on-call frequency	No more than every third night (averaged over four weeks) for second-year resident physicians and above	No more than every third night (averaged over four weeks)	No guidance	No more than once every three nights, no averaging
Minimum time off between scheduled shifts	8-10 hours between duty periods 14 hours free of duty after 24 hours of in-house duty	Eight hours between scheduled clinical work and education periods 14 hours off clinical work and education after 24 hours of in-house call	No guidance 12 hours off clinical work and education after 24 hours of in-house call	At least 10 hours off work after a day shift and a minimum of 12 hours off work after a night shift No extended work shifts

Background

As detailed in Public Citizen’s 2025 petition to the Occupational Health and Safety Administration (OSHA) to implement work-hour regulations for all resident physicians, substantial evidence demonstrates that long work hours and extended shifts are associated with sleep deprivation and fatigue among resident physicians, with profound effects on their health, safety, and well-being.[6] Sleep-deprived resident physicians have an increased risk of needlestick injuries, motor vehicle crashes, depression, burnout, and other mental health conditions. Pregnant resident physicians are at a higher risk of obstetric complications. Impaired sleep from long work hours has also been linked to increased medical errors, attentional failures, and preventable adverse events for patients.

Research has also demonstrated that reduced work hours help to mitigate these risks and have an overall positive effect on patient safety outcomes without significantly reducing

educational and clinical experiences of resident physicians. Evidence-based work-hour standards for resident physicians are essential for patient safety and to ensure humane and safe work environments.

Because the ACGME common program requirements lack work-hour standards that follow evidence-based recommendations, Public Citizen and co-petitioners petitioned OSHA in 2001[7] and 2010[8] and OSHA and the Centers for Medicare and Medicaid Services in 2025[9]  to implement these key requirements for resident physicians in all residency and subspecialty fellowship programs:

(1) A limit of 80 hours of work in each and every workweek, without averaging;

(2) A limit of 16 consecutive hours worked in one shift for all resident physicians and

subspecialty resident physicians, with no exceptions;

(3) At least one 24-hour period of time off work per week (no averaging) and one 48-

hour period of time off work per month, no averaging;

(4) In-hospital on-call frequency of no more than once every three nights, no averaging;

(5) A minimum of at least 10 hours off work after a day shift and a minimum of 12 hours

off work after a night shift; and

(6) A maximum of four consecutive night shifts with a minimum of 48 hours off after a sequence of three or four night shifts.

By reorganizing and condensing program requirements, the proposed major revision represents a 43% reduction of these requirements, according to the ACGME.[10] Instead of strengthening work-hour protections, however, the reduction of requirements prioritizes alleviating scheduling challenges, not the well-being and safety of resident physicians and the patients they care for. It is noteworthy that resident physicians and fellows and quality/patient safety officers were less involved in the surveys that were part of the ACGME’s process (8% and 13% of the respondents to two surveys, and 0.4% and 0.2%, respectively) than were program directors (34% and 37% of the respondents) and program coordinators (24% and 18% of the respondents).[11]

As the organization is solely responsible for setting and monitoring work-hour standards for resident physicians, the ACGME must establish evidence-based work-hour protections that 1) protect the safety of resident physicians, 2) help to reduce medical errors, and 3) contribute to a safer, better standard of patient care. We urge the ACGME to require work-hour enforcement and provide adequate guidance to ACGME-accredited programs on how standards can be best enforced and how to track violations. Inadequate enforcement has undermined previous efforts to limit resident physician work hours.

Public Citizen urges the ACGME to reconsider several of the proposed changes to the common program requirements:

1. Maximum hours of work per week (#6.29)

Although Public Citizen agrees with the ACGME proposal to no longer grant “rotation specific exceptions for … a maximum of 88 clinical and educational work hours” per week, the maximum of 80 hours work per week are still proposed to be averaged over four weeks.[12]

As detailed in Public Citizen’s 2025 OSHA petition, there is a substantial body of evidence demonstrating that excessive workweeks and extended shifts are harmful to both resident physicians and the patients they care for. We are concerned that averaging maximum work hours over a four-week period will allow programs to require resident physicians at times to work significantly longer hours in one week. We urge the ACGME to require a maximum of 80 work hours per week, without averaging.

We are also concerned that the ACGME proposes that “[a]ctivities such as reading about the next day’s case, studying, or research activities do not count toward the 80-hour weekly limit.” [13]

2. Minimum time off between scheduled shifts (#6.30 and #6.31)

The ACGME proposes to delete the requirement that “[R]esidents should have eight hours off between scheduled clinical work and education periods” and to shorten the hours free of clinical work and education after 24 hours of in-house call from 14 to 12 hours.[14] These changes are significant rollbacks of workplace protections. Public Citizen disagrees with ACGME’s assessment that this change will have no impact or not have “a significant impact” on resident/fellow education or patient safety. As discussed in our petition, long work hours and extended shifts are associated with sleep deprivation and fatigue. Moreover, acute and chronic sleep deprivation has detrimental effects on the health and safety of resident physicians and the patients under their care.

Based on the evidence presented in Public Citizen’s 2025 OSHA petition, we urge the ACGME to require that resident physicians never work shifts longer than 16 consecutive hours and have at least 10 hours off work after a day shift and a minimum of 12 hours off work after a night shift.

We are also concerned by the ACGME’s rationale for removing the requirement for eight hours off between shifts: the 80-hour-per-week limit would make it difficult “to design a schedule that provides fewer than eight hours off.” [15] Scheduling convenience for programs is an unacceptable reason to significantly roll back workplace protections for resident physicians. Programs must always prioritize the health and safety of resident physicians and the patients under their care.

The proposed revisions do not provide guidance on what the minimum time off between scheduled shifts should be. As a result, reporting certain violations may be impossible and the ability to enforce work-hour standards will be diminished. The justification for this change seems to be that the previous requirement of eight hours off between scheduled shifts was “not subject to citation for failure to meet this standard.” [16] Instead of making the minimum time off between shifts even less enforceable as a requirement, we urge the ACGME to insist that all programs comply with all work-hour requirements for resident physicians and to maintain the requirement that “[R]esidents should have eight hours off between scheduled clinical work and education periods.”

The ACGME’s rationale for reducing the hours free of clinical work and education after 24 hours of in-house call is “to reduce burden related to developing resident schedules.” [17] As previously stated, scheduling convenience for programs is an unacceptable reason to significantly roll back workplace protections for resident physicians. The wellness and safety of resident physicians and the patients in their care must always be prioritized.

3. Maximum in-hospital on-call frequency (#6.38)

The proposed revisions remove any guidance on the maximum in-hospital on-call frequency and delete the requirement that in-house on-call shifts occur “no more frequently than every third night (when averaged over a four-week period).”[18] By not providing guidance on the maximum on-call frequency, the ACGME would make the enforcement of safe limits as well as the reporting of work-hour violations effectively impossible. Public Citizen urges the ACGME to require that in-hospital on-call frequency should occur no more than once every three nights, with no averaging over a four-week period.

The stated rationale for this change is that the 80-hour workweek requirement would “make it nearly impossible for a program to assign a resident in-house call more frequently than once every third night on average.” [19] This might be the case if there was a limit of 80 hours of work in every workweek, without averaging. However, the proposed changes permit averaging of work hours over four weeks. Since the ACGME states that “monitoring compliance with the requirement [for maximum in-hospital on-call frequency] adds burden,” the proposed changes again prioritize convenience for residency programs over the wellness and safety of resident physicians and the patients in their care.

4. Less focus on the risks of sleep deprivation and fatigue (#6.16 and #6.24)

Resident physicians are at a particularly high risk of sleep deprivation. They frequently are required to work long hours, often with little opportunity to sleep during extended shifts.[20] There is extensive evidence that for resident physicians across specialties, sleep loss associated with shifts of more than 16 consecutive hours has detrimental effects, both for their own well-being and for the safety of the patients in their care. For this reason, recognizing and mitigating the health risks of sleep deprivation and fatigue must be an integral part of ACGME’s program requirements.

The proposed revisions of the common program requirements lack focus on the risks of sleep deprivation and fatigue. For instance, the ACGME suggests deleting the requirement that programs must educate resident physicians and faculty members concerning “their obligation to be appropriately rested and fit to provide the care required by their patients (6.16)” and in recognizing “the signs of fatigue and sleep deprivation, alertness management, and fatigue mitigation processes (6.24).”^[21]

Instead, the revised program requirements only state that “[T]he program … must ensure healthy and safe learning and working environments that promote resident well-being and provide for” (1.8) “safe, quiet, clean, and private sleep/rest facilities” (1.8.b.) and “safe options for residents who may be too fatigued to safely return home” (1.8.c).[22]

Resident physicians are often unable to objectively rate their own sleepiness or may think that they can acclimate to sleep deprivation. Despite being severely fatigued, they may feel that they can continue to function, learn, or care for patients. Public Citizen disagrees that the proposed “requirements appropriately address fatigue” and that the “education in fatigue and sleep deprivation” was only a “’checkbox’ exercise without additional benefit” to resident physicians.[23]

In addition to requiring sleep facilities and safe options for resident physicians who are too fatigued to return home safely, residency programs must continue to emphasize the recognition and education of resident physicians about the harms of fatigue and sleep deprivation for themselves and the patients in their care.

In summary, Public Citizen urges the ACGME to revise its program requirements in line with evidence-based work-hour protections highlighted in our 2025 OHSA petition. These program requirements would protect the safety and well-being of resident physicians and contribute to a safer, better standard of patient care.

Thank you for your consideration of our comments regarding this important issue.

 

Sincerely,

 

Nina Zeldes, Ph.D.

Senior Health Researcher, Health Research Group

Public Citizen

1600 20^th St. NW

Washington, D.C. 20009

[1] Institute of Medicine. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, National Research Council. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Ulmer C, Miller Wolman D, Johns MME, editors. Washington (DC): The National Academies Press; 2009.

[2] Accreditation Council for Graduate Medical Education. The ACGME 2011 duty hour standards: enhancing quality of care, supervision, and resident professional development. 2011. https://www.acgme.org/globalassets/pdfs/jgme-monograph1.pdf. Accessed October 22, 2026.

[3] Accreditation Council for Graduate Medical Education. ACGME common program requirements (residency). September 17, 2022. https://www.acgme.org/globalassets/pfassets/programrequirements/cprresidency_2022v3.pdf. Accessed October 22, 2026.

[4] Accreditation Council for Graduate Medical Education. ACGME common program requirements (residency). Proposed major revision. September 8, 2028. https://www.acgme.org/globalassets/pfassets/reviewandcomment/2026/cprresidency_rc_09082026.pdf. Accessed October 22, 2026.

[5] Public Citizen. Petition to OSHA to implement work-hour regulations for all resident physicians. May 20, 2025. https://www.citizen.org/article/re-petition-to-osha-to-implement-work-hour-regulations-for-all-resident-physicians/. Accessed October 22, 2026.

[6] Ibid

[7] Public Citizen. Petition requesting medical residents work hour limits. April 30, 2001. https://www.citizen.org/article/petition-requesting-medical-residents-work-hour-limits/. Accessed October 22, 2026.

[8] Public Citizen. Petition to reduce medical resident work hours. September 2, 2010. https://www.citizen.org/article/petition-to-reduce-medical-resident-work-hours-2/. Accessed October 22, 2026.

[9] Public Citizen. Public Citizen petitions OSHA and CMS to implement work-hour regulations for resident physicians. May 20, 2025. https://www.citizen.org/article/public-citizen-petitions-osha-and-cms-to-implement-work-hour-regulations-for-resident-physicians/. Accessed October 22, 2026.

[10] Accreditation Council for Graduate Medical Education. ACGME common program requirements major revision rationale and impact statement. https://www.acgme.org/globalassets/pfassets/reviewandcomment/2026/cpr_impact_09082026.pdf. Accessed October 22, 2026.

[11] Koh NJ, Alston MJ, Buser BR, et al. The ACGME common program requirements major revision process: Engaging the graduate medical education community. J Grad Med Educ. 2026 Aug 1;18(4):510-514.

[12] Accreditation Council for Graduate Medical Education. ACGME common program requirements major revision rationale and impact statement. https://www.acgme.org/globalassets/pfassets/reviewandcomment/2026/cpr_impact_09082026.pdf. Accessed October 22, 2026.

[13] Accreditation Council for Graduate Medical Education. ACGME common program requirements (residency). Proposed major revision. September 8, 2028. https://www.acgme.org/globalassets/pfassets/reviewandcomment/2026/cprresidency_rc_09082026.pdf. Accessed October 22, 2026.

[14] Accreditation Council for Graduate Medical Education. ACGME common program requirements major revision rationale and impact statement. https://www.acgme.org/globalassets/pfassets/reviewandcomment/2026/cpr_impact_09082026.pdf. Accessed October 22, 2026.

[15] Ibid.

[16] Ibid.

[17] Ibid.

[18] Ibid.

[19] Ibid.

[20] Public Citizen. Petition to OSHA to implement work-hour regulations for all resident physicians. May 20, 2025. https://www.citizen.org/article/re-petition-to-osha-to-implement-work-hour-regulations-for-all-resident-physicians/. Accessed October 22, 2026.

[21] Accreditation Council for Graduate Medical Education. ACGME common program requirements (residency). Proposed major revision. September 8, 2028. https://www.acgme.org/globalassets/pfassets/reviewandcomment/2026/cprresidency_rc_09082026.pdf. Accessed October 22, 2026.

[22] Ibid.

[23] Accreditation Council for Graduate Medical Education. ACGME common program requirements major revision rationale and impact statement. https://www.acgme.org/globalassets/pfassets/reviewandcomment/2026/cpr_impact_09082026.pdf. Accessed October 22, 2026.