Work Hours, Well-Being and Fatigue Mitigation


Department of Neurological Surgery – Residency Program Policy

Policy: Work Hours, Well-Being and Fatigue Mitigation

Program Chair:  Michael Rosner, MD

Last Revision: March 11, 2020


This policy is designed to ensure an appropriate work environment for residents of The George Washington University School of Medicine and Health Sciences Program in Neurological Surgery.


The following applies to all residency and fellowship training programs at The George Washington University School of Medicine and Health Sciences.

  1. Each residency program must have a formal written policy governing resident duty hours consistent with ACGME Institutional and Program Requirements.
  2. Program policies must be approved by the GME Committee and distributed to residents and faculty.
  3. The educational goals of the program and learning objectives of residents must not be compromised by excessive reliance on residents to fulfill service obligations.  Monitoring of duty hours is required with frequency sufficient to ensure an appropriate balance between education and service.  Didactic and clinical education must have priority in the allotment of residents’ time and energies. 
  4. The program must provide services and develop systems to minimize the work of residents that are extraneous to their educational programs.  Residents must be provided with appropriate backup support when patient care responsibilities are especially difficult or prolonged.
  5. Program policies must document that all participating institutions used by the residents assure that the duty hour requirements are met.
  6. The program must educate faculty and residents regarding the symptoms of depression, burnout, and substance abuse. The program must also provide self-screening tools and access to confidential mental health assessment/treatment.


Mandatory Time Free of Duty

Residents must be scheduled for a minimum of one day free of duty every week (when averaged over four weeks).  At-home call cannot be assigned on these free days.

Maximum Weekly Duty Hours

  1. Duty hours must be limited to 80 hours per week, averaged over a four-week period, including all in-house clinical and educational activities, clinical work done from home, and all moonlighting.
  2. Clinical and educational work periods for residents must not exceed 24 hours of continuous scheduled clinical assignments. .
  3. Up to four hours of additional time may be used for activities related to patient safety, such as providing effective transitions of care, and/or resident education.
  4. Residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.
  5. In unusual circumstances, residents, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient.  Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family.  In these circumstances, the resident must appropriately hand over care of all other patients to the team responsible for their continuing care.

Minimum Time Off between Scheduled Duty Periods

  1. The program must design an effective program structure that is configured to provide residents with educational opportunities, as well as reasonable opportunities for rest and personal well-being. 
  2. Residents should have eight hours off between scheduled clinical work and education periods.

i. There may be circumstances when residents choose to stay to care for their patients or return to the hospital with fewer than eight hours free of clinical experience and education. This must occur within the context of the 80- hour and the one-day-off-in-seven requirements. 

  1. Residents must have at least 14 hours free of clinical work and education after 24 hours of in-house call.

Maximum Frequency of In-House Night Float

Night float must occur within the context of the 80-hour and one-day-off-in-seven requirements.

Night float should be limited to four months per year, and must not exceed six months per year.

Work Hours, Well-Being and Fatigue Mitigation

PGY 2 residents and above must be scheduled for in-house call no more frequently than every 3rd night, when averaged over a 4-week period. 

At-Home Call

  1. Time spent in the hospital by residents on at-home call must count towards the 80-hour maximum weekly hour limit.  The frequency of at-home call is not subject to the every-third-night limitation, but must satisfy the requirement for one-day-in-seven free of duty when averaged over four weeks. 
  2. At home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident. 
  3. Residents are permitted to return to the hospital while on at-home call to care for new or established patients. Each episode of this type of care, while it must be included in the 80-hour weekly maximum, will not initiate a new “off-duty period”.


Neurosurgery residents are not permitted to moonlight.



As the sponsoring institution, The George Washington University School of Medicine and Health Sciences, through its Graduate Medical Education Committee, is responsible for promoting education and for ensuring that the working environment and duty hours are appropriate and in compliance with institutional and program requirements.  This is accomplished by the GMEC through the following methods:

  1. Review of programs' policies on work hours and resident working environment as part of the GMEC internal review process
  2. Continuous review of monthly duty hours reports from the MedHub system. 
  3. Monitoring the anonymous, web-based “Suggestion Box” for Duty Hour-related reports:
  4. Review of call schedules, OR schedules, and medical records as needed.

Residents are required to log duty hours at least once per week, without exception. Failure to do so will result in a deficiency in Professionalism.


  1. The Program Director and DIO (or designee) will review monthly duty hour reports from the MedHub system and address any violations. This will be reported to the GMEC when violations are noted. 
  2. The Program Director will report duty hours annually through the ACGME Web Accreditation System as part of the Annual Update. The DIO will review results of the duty hour section of the ACGME Resident Survey as part of the Annual Program Evaluation. Program Directors will be required to provide a response to any areas of noncompliance related to duty hours.
  3. All residents/fellows, Program Directors, and designated faculty are required to complete the sleep education training program developed and adapted from the SAFER program of the American Academy of Sleep Medicine. Compliance will be monitored by the GMEC.


  1. Residents must be given the opportunity to attend medical, mental health, and dental care appointments, including those scheduled during their working hours.  Residents should notify the chief resident prior to the date of these appointments if possible in order to ensure appropriate patient care and coverage of the Neurosurgery service. 
  2. Residents and faculty are encouraged to notify the program director or supervising faculty member when they are concerned another team member is displaying symptoms consistent with substance abuse, burnout or suicidal ideation.

Fatigue Mitigation

  1. Residents are encouraged to employ fatigue mitigation processes to prevent the deleterious effects of fatigue with respect to patient care and resident education.  Adequate call room facilities are maintained at George Washington University Hospital for use if a resident is too tired to safely drive home.  
  2. Alternatively, GWU SMHS Office of GME provides a “Trainee Taxi Voucher / Transportation Reimbursement Program” to provide reimbursement for local taxi or corporate ride-hailing companies.  Residents should contact Nursing Administration (202-715-5330) 15-30 minutes prior to leaving the hospital in order to obtain the taxi voucher.  For ride-hailing companies, the resident should obtain a receipt from the driver.  This can be submitted, no later than one week after use, to the GME office for reimbursement.

Approved by GMEC: 4/20/2020