A Systematic Review of the Effects of Resident Duty Hour Restrictions in Surgery: Impact on Resident Wellness, Training, and Patient Outcomes

Ahmed, Najma MD*; Devitt, Katharine S. MSc*; Keshet, Itay MD; Spicer, Jonathan MD; Imrie, Kevin MD§; Feldman, Liane MD; Cools-Lartigue, Jonathan MD; Kayssi, Ahmed MD*; Lipsman, Nir MD*; Elmi, Maryam MD*; Kulkarni, Abhaya V. MD*; Parshuram, Chris MD; Mainprize, Todd MD*; Warren, Richard J. MD; Fata, Paola MD; Gorman, M. Sean MD**; Feinberg, Stan MD*; Rutka, James MD*

doi: 10.1097/SLA.0000000000000595
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Background: In 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated 80-hour resident duty limits. In 2011 the ACGME mandated 16-hour duty maximums for PGY1 (post graduate year) residents. The stated goals were to improve patient safety, resident well-being, and education. A systematic review and meta-analysis were performed to evaluate the impact of resident duty hours (RDH) on clinical and educational outcomes in surgery.

Methods: A systematic review (1980–2013) was executed on CINAHL, Cochrane Database, Embase, Medline, and Scopus. Quality of articles was assessed using the GRADE guidelines. Sixteen-hour shifts and night float systems were analyzed separately. Articles that examined mortality data were combined in a random-effects meta-analysis to evaluate the impact of RDH on patient mortality.

Results: A total of 135 articles met the inclusion criteria. Among these, 42% (N = 57) were considered moderate-high quality. There was no overall improvement in patient outcomes as a result of RDH; however, some studies suggest increased complication rates in high-acuity patients. There was no improvement in education related to RDH restrictions, and performance on certification examinations has declined in some specialties. Survey studies revealed a perception of worsened education and patient safety. There were improvements in resident wellness after the 80-hour workweek, but there was little improvement or negative effects on wellness after 16-hour duty maximums were implemented.

Conclusions: Recent RDH changes are not consistently associated with improvements in resident well-being, and have negative impacts on patient outcomes and performance on certification examinations. Greater flexibility to accommodate resident training needs is required. Further erosion of training time should be considered with great caution.

A systematic review and meta-analysis were performed to evaluate the impact of resident duty hours (RDH) on clinical and educational outcomes in surgery. A total of 135 articles met inclusion criteria. In surgery, recent RDH changes are not consistently associated with improved resident well-being and may have negative impacts on patient outcomes and education.

*Department of Surgery, University of Toronto, Toronto, Ontario, Canada

Department of Internal Medicine, Mount Sinai Hospital, New York City, NY

Department of Surgery, McGill University, Montreal, Quebec, Canada

§Department of Internal Medicine, University of Toronto, Toronto, Ontario, Canada

Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada

Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada

**Department of Surgery, Royal Inland Hospital, Kamloops, British Columbia, Canada.

Reprints: Najma Ahmed, MD, Division of General Surgery, St Michael's Hospital, Rm 3073, Donnelly Wing, 30 Bond Street, Toronto, Ontario, Canada, M5W 1B8. E-mail: ahmedn@smh.ca.

Disclosure: This study was supported by Health Canada and the Department of Surgery, University of Toronto, Ontario, Canada. The authors declare that they have no conflict of interest.

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© 2014 by Lippincott Williams & Wilkins.