doctors, american medical residents are required to enter into a contract to accept whatever residency position they are assigned; they are then matched to a job by the aamc and told what the working conditions and pay are. the plaintiffs allege that this is an anti-competitive practice, and that the defendants artificially limit the number of resident positions available. the suit had some early success, but failed when the u.s. congress enacted the pension funding equity act in 2004, which exempting matching programs from federal antitrust laws. where there is a shortage of doctors, proposed solutions include reducing the costs of medical training and more extensive training for nurses, who then take over duties formerly done by doctors. improving the working conditions of doctors might also increase recruitment and decrease burnout leading to fewer doctors leaving medicine. eu regulation junior doctors in the european union fall under the european working time directive, which specifies: 48 working hours per week (down from 56 under the old uk regulations), calculated over a period of 26 weeks. 11 hours continuous rest per day one day off each week, or two days off each fortnight 20 minutes of continuous rest every 6 hours however, junior doctors may choose to work more than 48 hours a week, or opt out of the ewtd entirely by signing a waiver with the employer. they may not be punished for not working more than the directed hours. many trainees nonetheless feel obliged to work longer hours. the rest times are mandatory, but may be taken at another time if it cannot be taken as scheduled. american regulation the issue is politically controversial in the united states, where federal regulations did not limit the number of hours that can be assigned during a graduate medical student's medical residency. starting in 2003, with revisions in 2011, regulations from the accreditation council for graduate medical education capped the work-week at 80 hours. as of 2018, shifts are capped (with limited exceptions) at a maximum of 24 consecutive hours of direct patient care with an additional 4 hours for transition of care (sign out, completing notes, etc.) for first, second, and third year residents. the accreditation council for graduate medical education (acgme) has limited the number of work-hours to 80 hours weekly, overnight call frequency to no more than one in three, 30-hour maximum straight shifts, and at least 10 hours off between shifts. while these limits are voluntary, adherence has been mandated for accreditation. the institute of medicine (iom) built upon the recommendations of the acgme in the december 2008 report resident duty hours: enhancing sleep, supervision and safety. while keeping the acgme's recommendations of an 80-hour work week averaged over 4 weeks, the iom report recommends that duty hours should not exceed 16 hours per shift for interns (pgy 1). the iom also recommended strategic napping between the hours of 10pm and 8am for shifts lasting up to 30 hours. the acgme officially recommended strategic napping between the hours of 10pm and 8am on 30-hour shifts for residents who are post graduate year 2 and above but did not make this a requirement for program compliance. the report also suggests residents be given variable off-duty periods between shifts, based on the timing and duration of the shift, to allow residents to catch up on sleep each day and make up for chronic sleep deprivation on days off. though the acgme regulations were intended to increase medical resident sleep hours and improve patient safety, they had also created unintended negative consequences in the education of new residents and the workplace learning culture. in 2017, the acgme changed its regulations once again, citing a trial conducted from july 2014 to june 2015 in 117 general surgery residency programs. in the flexibility in duty hour requirements for surgical trainees (first) trial, programs were randomly assigned to a group following current acgme duty-hour restrictions or a group with more flexible policies that waived rules on maximum shift lengths and time off between shifts. when looking at primary outcomes of 30-day rate of postoperative death or serious complications, less-restrictive duty-hour policies were not associated with an increased rate of death or serious complications. starting july 1, 2017, the acgme raised the maximum number of consecutive hours a first year resident can work from 16 hours to 24 hours. despite the sleep deprivation medical residents constantly experience due to long working hours, a minority of residents still wish to not have work hour regulations at all. in the survey of 4510 obstetric-gynecologic residents, about one in five opposed any limits on their work hours. these residents cited "additional experience" as the most common reason (69.0%), followed by "opportunity to see rare cases" (46.5%) and "continuity with patients" (31.8%). towards an 80-hour work week the libby zion case, in which an 18-year-old college student died of a drug interaction after being treated by a fatigued intern and resident in a new york hospital, led to the establishment of the bell commission in 1987 to address physician training hours. although the serotonin syndrome was not widely known at the time (neither by the house staff nor the attending physician), the bell commission continued to address the house officer sleep deprivation issue. its recommendations were adopted by the state of new york in 1989, and limited residents to no more than 24 consecutive hours in the hospital, and no more than 80 hours a week with an in-house supervising attending physician present at all times. though other federal regulatory and legislative attempts to limit medical resident work hours have materialized, none have attained passage. dr. richard corlin, president of the american medical association, has called for re-evaluation of the residency training process, declaring "we need to take a look again at the issue of why is the resident there." the u.s. occupational safety and health administration (osha) rejected a petition seeking to restrict medical resident work hours, opting to rely on standards adopted by acgme, a private trade association that represents and accredits residency programs. on july 1, 2003, the acgme instituted duty hours requirements for all accredited residency programs, since revised in 2011. the acgme duty hour standards that went into effect in july 2003 require: an 80-hour weekly limit, averaged over 4 weeks, inclusive of all in-house call activities; a 10-hour rest period between duty periods and after in-house call; a 24-hour limit on continuous duty, with up to 6 additional hours for continuity of care and education; no new patients to be accepted after 24 hours of continuous duty; one day in 7 free from patient care and educational obligations, averaged over 4 weeks, inclusive of call; and in-house call no more than once every 3 nights, averaged over 4 weeks. following the acgme's proposed regulation of duty hours the american osteopathic association (aoa) followed suit. below are the requirements adopted by the american osteopathic association. the trainee shall not be assigned to work physically on duty in excess of 80 hours per week averaged over a 4-week period, inclusive of in-house night call. the trainee shall not work in excess of 24 consecutive hours inclusive of morning and noon educational programs. allowances for inpatient and outpatient continuity, transfer of care, educational debriefing and formal didactic activities may occur, but may not exceed 6 hours. residents may not assume responsibility for a new patient after working 24 hours. the trainee shall have on alternate weeks 48-hour periods off, or at least one 24-hour period off each week, averaged over a 4-week period. upon conclusion of a 24-hour duty shift, trainees shall have a minimum of 10 hours off before being required to be on duty again. upon completing a lesser hour duty period, adequate time for rest and personal activity must be provided. all off-duty time must be totally free from assignment to clinical or educational activity. rotations in which trainee is assigned to emergency department duty shall ensure that trainees work no longer than 12-hour shifts. the trainee and training institution must always remember the patient care responsibility is not precluded by the work hour policy. in cases where a trainee is engaged in patient responsibility which cannot be interrupted, additional coverage should be provided as soon as possible to relieve the resident involved. the trainee may not be assigned to call more often than every third night averaged over any consecutive four-week period. another related issue regarding the imposition of maximum hour policies for medical residents is the question of enforcement, where some enforcement proposals have included extending u.s. federal whistle-blower protection to medical residents in order to ensure compliance and afford medical residents certain employment protection. there are still inherent problems with the current acgme policy. resident duty hour restrictions are difficult to assess and enforce. also, it is unclear who is ultimately responsible for monitoring duty hour adherence (i.e. state licensing boards, residency programs, attendings, residents, etc.). additionally, a one-size-fits all solution may not be ideal, since the need for certain duty hours may vary among specialties. coping mechanisms although strategic napping is recommended by the acgme, no studies have assessed the effect of napping as a fatigue mitigation technique. requiring naps during long shifts could be a small step toward reducing fatigue and potentially decreasing errors. resident surveys suggest that a greater emphasis on education, decreased workload, and more ancillary support would better improve patient outcomes. focusing on hospital best practices and physician incentives like pay-for-performance in residency could help with the implementation of some of these solutions. techniques to reduce circadian misalignment include avoiding abrupt changes in shift time, getting more sleep, which makes the sleep schedule more flexible, and the use of caffeine and ambient light of specific wavelengths.