Key facts
- ACGME limits clinical and educational work to no more than 80 hours per week averaged over four weeks, including work from home and moonlighting.
- Continuous scheduled clinical work must not exceed 24 hours, with up to four more hours allowed for transitions of care and education.
- Residents must have at least one day in seven free of clinical work and required education, averaged over four weeks.
- Documentation, shared decision-making and structured feedback are everyday parts of US training, and the skills can be learned quickly.
The core skills of medicine are the same everywhere, but how US hospitals organise work, documentation and communication can feel different, even to an excellent clinician. This page describes common patterns and the formal rules that apply to resident working hours. It describes the system and not any group of people, and every hospital and specialty varies, so use it as a starting list of questions.
The formal rules: ACGME work hours #
The Accreditation Council for Graduate Medical Education (ACGME) sets the Common Program Requirements for accredited residency programs. The version I verified is the 2023 residency requirements (Section VI.F). Check the ACGME site for the current text and for your specialty's own requirements, which can add detail.
| Rule | What the requirements say |
|---|---|
| Weekly limit | No more than 80 hours per week, averaged over four weeks, inclusive of in-house clinical and educational activities, clinical work from home, and all moonlighting |
| Longest shift | Clinical and educational work periods must not exceed 24 hours of continuous scheduled clinical assignments |
| Transition time | Up to four additional hours may be used for patient safety activities such as handoffs, or education. No new patient care duties in that time. It counts toward the 80 hours |
| Rest after 24-hour call | At least 14 hours free of clinical work and education after 24 hours of in-house call |
| Days off | At least one day in seven free of clinical work and required education, averaged over four weeks |
| In-house call | No more often than every third night, averaged over four weeks |
| Exceptions | A Review Committee may grant limited rotation-specific exceptions, up to a maximum of 88 hours a week in the 2023 text |
Another point that often surprises new residents: reading and studying done at home do not count toward the 80 hours, but clinical work from home, such as EHR work, does.
Team structure and hierarchy #
US teaching hospitals work in layers: medical students, interns (PGY-1), senior residents, sometimes fellows, and an attending physician who is legally responsible for the patient. Attending supervision is a requirement of training, and you will be expected to present to and ask questions of your supervisors.
Practical points:
- Know who to call. Learn when to escalate and to whom. Calling a senior or attending early about a sick patient is expected and is not a sign of weakness.
- Nurses, pharmacists, social workers and case managers are core members of the team. Respectful working relationships make your day easier.
- Titles and tone. Many hospitals use first names, even for attendings, but follow the local norm until you learn it. Ask a senior resident.
- Chain of command exists for patient safety and for concerns about conduct.
Communication #
- Be direct and concise. Oral presentations follow a structure (for example, one-liner, history, exam, assessment, plan). Learn your team's format.
- Say what you do not know. Residents are expected to ask. Guessing at a medication dose is a patient safety risk.
- Use clear, closed-loop communication for orders and handoffs: repeat back, confirm, document.
- Language and accent. Nobody expects a particular accent, but clarity matters. If you are asked to repeat yourself, slow down, and confirm that you were understood. The Occupational English Test page covers the formal test for IMGs.
- Written messages in secure messaging apps are short and specific. Include the patient, location, question and urgency.
Patient interaction #
- Informed consent and shared decision-making are central. Patients usually expect a clear explanation of options, risks and alternatives, and expect to take part in decisions.
- Interpreters. Hospitals provide professional interpreters for patients with limited English. Use them rather than family members when you can, and follow your hospital's policy.
- Privacy and boundaries. US privacy law (HIPAA) shapes how you discuss patients, where you talk, and what you put in messages. Do not share patient information on personal apps or photographs.
- Cultural humility. Patients bring varied beliefs and expectations. Ask open questions, and learn the vocabulary your patients use for symptoms.
- Telling bad news and discussing goals of care are practised skills. Ask for observation and feedback from seniors.
Documentation and the EHR #
- If it is not documented, it did not happen is a common saying. Notes support patient care, billing and legal review.
- Electronic health record (EHR) systems such as those used by your hospital are large, and orientation includes training. Learn the order entry, results and handoff tools in your first week. Ask for tip sheets.
- Templates and copy-forward save time but can carry errors. Review what you paste.
- Supervisors co-sign many notes and orders. Know which orders need an attending's approval.
- Time pressure. Expect documentation to take a large share of the day. Plan your time and ask seniors for efficient workflows.
Feedback culture #
US training uses frequent, structured feedback and evaluation. ACGME requirements call for formative feedback and for programs to provide channels to report mistreatment. Evaluations are written by supervisors, nurses and others, and your Clinical Competency Committee reviews progress.
How to work with it:
- Ask for specific feedback during and after rotations, not only at the end.
- Expect direct comments. Feedback may be more frank than you are used to, and it is usually about the task, not about you personally. Reply with thanks and a plan.
- Praise and criticism both appear in writing. Read evaluations and discuss patterns with your program director or advisor.
- Speak up about errors. Reporting a near-miss through the hospital system is expected and protects patients.
Wellbeing and support #
The transition to the US combines a new job, a new country and often distance from family. Check what your institution offers: mentors or buddy residents, an international office, mental health services, and wellness programmes. ACGME addresses well-being in its requirements for programs and sponsoring institutions. Asking for help early is normal, and your GME office can explain confidential options.
A starting checklist #
- Ask your chief resident for the real-world schedule, call structure and sign-out process.
- Learn your hospital's duty-hour reporting method.
- Book EHR practice time during orientation.
- Find a senior resident or alumnus from your background or another IMG who can answer small questions.
- Read your program's leave, evaluation and grievance policies.
- Keep your non-work routines (sleep, food, contact with family) in your schedule from the first week.
Frequently asked questions
What are the duty-hour limits for residents?
ACGME sets no more than 80 hours a week averaged over four weeks, 24 hours maximum continuous scheduled work plus up to four hours for transitions, in-house call no more than every third night, and one day in seven free, averaged over four weeks. Verify on ACGME for your specialty.
Do these limits apply to moonlighting?
ACGME counts moonlighting inside the 80 hours. Visa and program rules also limit moonlighting. See the moonlighting page.
Is the system the same everywhere?
No. The ACGME framework is shared, but each hospital and specialty has its own norms. Ask senior residents.
What if I think I am being treated unfairly?
Start with your chief resident, program coordinator or program director. Institutions must also provide confidential ways to report concerns. Your GME office can explain them.
Sources
- ACGME: Common Program Requirements (Residency)
- ACGME: Common Program Requirements Section VI revision summary
- ACGME: Answers on resident leave policies
- ACGME: Institutional Requirements
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