Perspective: beyond counting hours: the importance of supervision, professionalism, transitions of care, and workload in residency training.

The medical education community's conversations about residents' duty hours have long focused solely on the number of those hours. In July 2011, the Accreditation Council for Graduate Medical Education (ACGME) enacted its most recent iteration of standards regarding duty hours. Those standards, as well as a 2008 Institute of Medicine report, look beyond the quantity of duty hours to address their quality as well. Indeed, the majority of the 2011 ACGME standards specify requirements for the qualitative components of residents' working and learning environments, including supervision of residents; professionalism, personal responsibility, and patient safety; transitions of care; and clinical responsibilities (including workload). The authors believe that focusing on these qualitative (rather than quantitative) components of the resident's working and learning environment provides the greatest promise for balancing patient care with resident education, thus optimizing the safety and effectiveness of both. For each of the four qualitative components that the authors discuss (enhancing supervision, nurturing professionalism and personal responsibility, ensuring safe transitions of care, and optimizing workloads and cognitive loads), they offer agendas for faculty development, educational program planning, and research. Thus, the authors call on the medical education community to expand its discussion beyond counting duty hours to focus on these critical issues that ensure quality resident education and patient care and to implement necessary strategies to address them.