the Accreditation Council for Graduate Medical Education (ACGME) enacted resident duty-hour standards for all accredited programs that sought to integrate limits on resident hours within the larger set of ACGME standards. The aim of these standards was to promote highquality learning and safe care in teaching institutions. 1 When the standards were established, the ACGME promised the profession that it would revisit them in 5 years.The educational community and the public have identified three elements of the 2003 standards as particularly problematic. First, the dutyhour limits may have created or exacerbated the adoption of a "shift mentality" during residency. This attitude may conflict with physicians' moral and professional responsibility to their patients and may leave residents unfamiliar with and unprepared for the hours and professional obligations of practicing physicians. Second, duty hours remained the primary focus for programs and institutions; larger changes in the learning environment that were envisioned when the duty-hour standards were instituted in 2003 never materialized. 2 Changes discussed extensively in the formulation of the current requirements included enhancing supervision and faculty oversight of care, improving handover practices, engaging in further study of the relationship between sleep and performance, and increasing the attention paid to safety as a systems issue. Third, the current limit on continuous duty is the subject of intensive debate, with lingering concerns that it may leave residents susceptible to the effects of acute sleep loss. Residents in surgical and inpatientintensive medical specialties also have difficulty complying with this standard, which places them in the ethical quandary of choosing between leav-ing patients in order to comply with "the rules" or violating the standard by remaining with a sick patient when they believe it is their professional responsibility. 3 Of added concern are reports suggesting that the 2003 limits did not increase residents' hours of sleep 4 or reduce fatigue 5,6 and that the added time created under the new standards is not being used by residents for reading and study. Most important, studies using national data samples failed to show that the duty-hour limits had a positive effect on the quality and safety of inpatient care. [7][8][9] Coincident with the 5-year anniversary of the standards, the Institute of Medicine (IOM) released the report Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. 10 It discussed attributes of the educational program beyond resident hours that promote patient safety in teaching hospitals, including appropriate supervision and transfers of care and a culture of safety in educational settings. The components that received the most attention, however, related to further modifications of the ACGME standards, the significant associated costs, and criticism of the effectiveness of the ACGME's enforcement of its duty-hour standards.In consultation with its Council of Review Committee Chairs, the...

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