A Systematic Review of the Effects of Resident Duty Hour Restrictions in Surgery

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.

[1]  D. Watson,et al.  Impact of the 80-hour workweek on surgical case exposure within a general surgery residency program. , 2010, Journal of surgical education.

[2]  S. Moffatt-Bruce,et al.  American Board of Thoracic Surgery examination: fewer graduates, more failures. , 2014, The Journal of thoracic and cardiovascular surgery.

[3]  R Core Team,et al.  R: A language and environment for statistical computing. , 2014 .

[4]  B. Schirmer,et al.  The night float system: ensuring educational benefit. , 2005, American journal of surgery.

[5]  M. Rothmund,et al.  Call-associated Acute Fatigue in Surgical Residents—Subjective Perception or Objective Fact? A Cross-sectional Observational Study to Examine the Influence of Fatigue on Surgical Performance , 2012, World Journal of Surgery.

[6]  P. Rosenbaum,et al.  Did Duty Hour Reform Lead to Better Outcomes Among the Highest Risk Patients? , 2009, Journal of General Internal Medicine.

[7]  Derek J Donegan,et al.  Early effects of resident work-hour restrictions on patient safety: a systematic review and plea for improved studies. , 2011, The Journal of bone and joint surgery. American volume.

[8]  Robert J. Crutcher,et al.  The role of deliberate practice in the acquisition of expert performance. , 1993 .

[9]  Katherine C. Kellogg,et al.  The Impact of the 80-Hour Resident Workweek on Surgical Residents and Attending Surgeons , 2006, Annals of surgery.

[10]  I. Philibert,et al.  Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships? , 2013, Annual review of medicine.

[11]  David J. Lick,et al.  Changing the Conversation From Burnout to Wellness: Physician Well-being in Residency Training Programs. , 2009, Journal of graduate medical education.

[12]  A. Davis,et al.  ACGME duty-hour restrictions decrease resident operative volume: a 5-year comparison at an ACGME-accredited university general surgery residency. , 2007, Journal of surgical education.

[13]  D. Hochman,et al.  Effect of an acute care surgical service on the timeliness of care. , 2013, Canadian journal of surgery. Journal canadien de chirurgie.

[14]  Howard Balshem,et al.  GRADE guidelines: 3. Rating the quality of evidence. , 2011, Journal of clinical epidemiology.

[15]  Francesina R. Jackson.  Outliers: The Story of Success , 2009 .

[16]  H. May,et al.  Effect of work-hour restriction on operative experience in cardiothoracic surgical residency training. , 2009, The Journal of thoracic and cardiovascular surgery.

[17]  A. Buczkowski,et al.  Effects of implementation of an urgent surgical care service on subspecialty general surgery training. , 2010, Canadian journal of surgery. Journal canadien de chirurgie.

[18]  B. Drolet,et al.  The 2011 duty-hour requirements--a survey of residency program directors. , 2013, The New England journal of medicine.

[19]  L. Brewster,et al.  The Perspective of the Vascular Surgery Trainee on New ACGME Regulations, Fatigue, Resident Training, and Patient Safety , 2011, Vascular and endovascular surgery.

[20]  J. R. Sádaba,et al.  Does the introduction of duty-hour restriction in the United States negatively affect the operative volume of surgical trainees? , 2011, Interactive cardiovascular and thoracic surgery.

[21]  A. Powell,et al.  The increased financial burden of further proposed orthopaedic resident work-hour reductions. , 2011, The Journal of bone and joint surgery. American volume.

[22]  Katherine M. James,et al.  Duty hour recommendations and implications for meeting the ACGME core competencies: views of residency directors. , 2011, Mayo Clinic proceedings.

[23]  Wolfgang Viechtbauer,et al.  Conducting Meta-Analyses in R with the metafor Package , 2010 .

[24]  K. Holt,et al.  Resident Operative Experience in General Surgery, Plastic Surgery, and Urology 5 Years After Implementation of the ACGME Duty Hour Policy , 2010, Annals of surgery.

[25]  Joseph M. Galante,et al.  Effect of the 16-hour work limit on general surgery intern operative case volume: a multi-institutional study. , 2013, JAMA surgery.

[26]  Debra F. Weinstein,et al.  Long-Term Follow-Up on the Educational Impact of ACGME Duty Hour Limits: A Pre-Post Survey Study , 2012, Annals of surgery.

[27]  C. Cook,et al.  Resident duty-hour reform associated with increased morbidity following hip fracture. , 2009, The Journal of bone and joint surgery. American volume.

[28]  M. Rotondo,et al.  The effect of a rotating night-float coverage scheme on preventable and potentially preventable morbidity at a level 1 trauma center. , 2005, American journal of surgery.

[29]  Eugene Kim,et al.  A 360 degrees evaluation of a night-float system for general surgery: a response to mandated work-hours reduction. , 2004, Current surgery.

[30]  Furman S. McDonald,et al.  Impact of resident workload and handoff training on patient outcomes. , 2012, The American journal of medicine.

[31]  B. Drolet,et al.  Residents' perspectives on ACGME regulation of supervision and duty hours--a national survey. , 2010, The New England journal of medicine.

[32]  R. Lewis,et al.  The 80-hour resident workweek does not adversely affect patient outcomes or resident education. , 2006, Current surgery.

[33]  S. Desai,et al.  Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: a randomized trial. , 2013, JAMA internal medicine.

[34]  J. Weigelt,et al.  Needlesticks and surgical residents: who is most at risk? , 2007, Journal of surgical education.

[35]  V. Arora,et al.  Patient Safety, Resident Education and Resident Well-Being Following Implementation of the 2003 ACGME Duty Hour Rules , 2011, Journal of General Internal Medicine.

[36]  T. Helling,et al.  The effect of resident duty hour restriction on trauma center outcomes in teaching hospitals in the state of Pennsylvania. , 2010, Journal of Trauma.

[37]  J. Lowery,et al.  Impact of reduction in working hours for doctors in training on postgraduate medical education and patients’ outcomes: systematic review , 2011, BMJ : British Medical Journal.

[38]  D. Teitelbaum,et al.  Impact of work-hour restrictions on residents' operative volume on a subspecialty surgical service. , 2005, Journal of the American College of Surgeons.

[39]  M. Makary,et al.  Needlestick injuries among surgeons in training. , 2007, The New England journal of medicine.

[40]  Benjamin K Poulose,et al.  Resident Work Hour Limits and Patient Safety , 2005, Annals of surgery.

[41]  Albert G Crawford,et al.  Cumulative operative experience is decreasing during general surgery residency: a worrisome trend for surgical trainees? , 2008, Journal of the American College of Surgeons.

[42]  Henry R. Kranzler,et al.  Effects of the 2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study. , 2013, JAMA internal medicine.

[43]  R. P. Jewell,et al.  Increased rate of complications on a neurological surgery service after implementation of the Accreditation Council for Graduate Medical Education work-hour restriction. , 2012, Journal of neurosurgery.

[44]  J. Kolars,et al.  Introduction of a 14-hour work shift model for housestaff in the medical ICU. , 2005, Chest.

[45]  J. Richardson,et al.  Brief communication of the Residency Review Committee-Surgery (RRC-S) on residents' surgical volume in general surgery. , 2005, American journal of surgery.

[46]  D. Deckelbaum,et al.  Abolishment of 24-hour continuous medical call duty in quebec: a quality of life survey of general surgical residents following implementation of the new work-hour restrictions. , 2013, Journal of surgical education.

[47]  H. Frankel,et al.  Are Resident Work-Hour Limitations Beneficial to the Trauma Profession? , 2006, The American surgeon.

[48]  W. Cioffi,et al.  Surgical residents' perceptions of 2011 Accreditation Council for Graduate Medical Education duty hour regulations. , 2013, JAMA surgery.

[49]  John Parboosingh,et al.  CPD and maintenance of certification in the Royal College of Physicians and Surgeons of Canada , 2003, Canadian Medical Association journal.

[50]  R. Kaderli,et al.  Morbidity in surgery: impact of the 50-hour work-week limitation in Switzerland. , 2012, Swiss medical weekly.

[51]  H. Saadat,et al.  Wellness program for anesthesiology residents: a randomized, controlled trial , 2012, Acta anaesthesiologica Scandinavica.

[52]  K. Horvath,et al.  Effects of duty hour restrictions on core competencies, education, quality of life, and burnout among general surgery interns. , 2013, JAMA surgery.

[53]  B. Kesser,et al.  Four years of accreditation council of graduate medical education duty hour regulations: Have they made a difference? , 2009, The Laryngoscope.

[54]  J. Mocco,et al.  Higher complications and no improvement in mortality in the ACGME resident duty-hour restriction era: an analysis of more than 107,000 neurosurgical trauma patients in the Nationwide Inpatient Sample database. , 2012, Neurosurgery.

[55]  A. Meyer,et al.  Psychologic well-being of surgery residents after inception of the 80-hour workweek: a multi-institutional study. , 2005, Surgery.

[56]  Cheryl Ulmer,et al.  Resident Duty Hours:Enhancing Sleep, Supervision, and Safety , 2014 .

[57]  G. E. Vates,et al.  Impact of the Accreditation Council for Graduate Medical Education work-hour regulations on neurosurgical resident education and productivity. , 2009, Journal of neurosurgery.

[58]  F. Lewis,et al.  Issues in general surgery residency training--2012. , 2012, Annals of surgery.

[59]  J. Britton,et al.  Standardized sign-out improves completeness and perceived accuracy of inpatient neurology handoffs , 2012, Neurology.

[60]  Karen Frush,et al.  Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements. , 2012, Academic medicine : journal of the Association of American Medical Colleges.

[61]  K. Itani,et al.  Effects of Resident Duty Hour Reform on Surgical and Procedural Patient Safety Indicators Among Hospitalized Veterans Health Administration and Medicare Patients , 2009, Medical care.

[62]  Kanaka D. Shetty,et al.  Changes in Hospital Mortality Associated with Residency Work-Hour Regulations , 2007, Annals of Internal Medicine.

[63]  A. Carlin,et al.  Effect of the 80-hour work week on resident operative experience in general surgery. , 2007, American journal of surgery.

[64]  T. Grantcharov,et al.  Laparoscopic performance after one night on call in a surgical department: prospective study , 2001, BMJ : British Medical Journal.

[65]  J. Barendregt,et al.  Systematic review and meta‐analysis of the effect of North American working hours restrictions on mortality and morbidity in surgical patients , 2012, The British journal of surgery.

[66]  N. Hogle,et al.  Limiting PGY 1 residents to 16 hours of duty: review and report of a workshop. , 2012, Journal of surgical education.

[67]  Position of the American College of Surgeons on restrictions on resident work hours. , 2009, Bulletin of the American College of Surgeons.

[68]  Asher Hirshberg,et al.  Impact of the 80-hour work week on resident emergency operative experience. , 2005, American journal of surgery.

[69]  A. Christmas,et al.  Operative Experience in the Era of Duty Hour Restrictions: Is Broad-Based General Surgery Training Coming to an End? , 2010, The American surgeon.

[70]  P. Rhee,et al.  Impact of the 80-hour workweek on patient care at a level I trauma center. , 2007, Archives of surgery.

[71]  C. Cassel,et al.  Service: an essential component of graduate medical education. , 2013, The New England journal of medicine.

[72]  Sadiq S. Rehmani,et al.  Surgical Residents’ Perception of the 16-Hour Work Day Restriction: Concern for Negative Impact on Resident Education and Patient Care , 2013 .

[73]  R. Lewis,et al.  Decreased bile duct injury rate during laparoscopic cholecystectomy in the era of the 80-hour resident workweek. , 2008, Archives of surgery.

[74]  A. Hölscher,et al.  Alternative shift models and the quality of patient care , 2001, Langenbeck's Archives of Surgery.

[75]  Christopher M. Hicks,et al.  A crisis of faith? A review of simulation in teaching team-based, crisis management skills to surgical trainees. , 2012, Journal of surgical education.

[76]  B. Nahed,et al.  Investigating the Scope of Resident Patient Care Handoffs within Neurosurgery , 2012, PloS one.

[77]  Dylan S. Small,et al.  Effect of a protected sleep period on hours slept during extended overnight in-hospital duty hours among medical interns: a randomized trial. , 2012, JAMA.

[78]  R. Kaderli,et al.  Resident work hour restrictions do not improve patient safety in surgery: a critical appraisal based on 7 years of experience in Switzerland , 2012, Patient Safety in Surgery.

[79]  J. Coselli,et al.  The impact of resident work-hour restrictions on outcomes of cardiac operations. , 2009, The Journal of surgical research.

[80]  R. Dell,et al.  Osteoporosis disease management: What every orthopaedic surgeon should know. , 2009, The Journal of bone and joint surgery. American volume.

[81]  S. Doi,et al.  Effect of the ACGME Duty Hours Restrictions on Surgical Residents and Faculty: A Systematic Review , 2011, Academic medicine : journal of the Association of American Medical Colleges.

[82]  L. McMahon,et al.  Effects of work hour reduction on residents' lives: a systematic review. , 2005, JAMA.

[83]  Matthew M. Wyatt,et al.  Impact of the 80-hour work week on mortality and morbidity in trauma patients: an analysis of the National Trauma Data Bank. , 2009, The Journal of surgical research.

[84]  E. Somers.  International Agency for Research on Cancer. , 1985, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[85]  C. Haisch,et al.  Accreditation Council for Graduate Medical Education Case Logs as an Indication of Operative Competency for Vascular Anastomoses: A Pilot Study , 2016 .

[86]  T. Osler,et al.  Implementation of Resident Work Hour Restrictions is Associated With a Reduction in Mortality and Provider-Related Complications on the Surgical Service: A Concurrent Analysis of 14,610 Patients , 2009, Annals of surgery.

[87]  Katherine C. Kellogg,et al.  Effect of work-hour reforms on operative case volume of surgical residents. , 2005, Current surgery.

[88]  Daniel B. Jones,et al.  General Surgery Residency Inadequately Prepares Trainees for Fellowship: Results of a Survey of Fellowship Program Directors , 2013, Annals of surgery.

[89]  J. Coselli,et al.  Impact of ACGME work-hour restrictions on the outcomes of coronary artery bypass grafting in a cohort of 600,000 patients. , 2010, The Journal of surgical research.

[90]  K. Fargen,et al.  Results of a national neurosurgery resident survey on duty hour regulations. , 2012, Clinical neurosurgery.

[91]  Kevin G Volpp,et al.  Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. , 2007, JAMA.

[92]  Scott D. Martin,et al.  Concomitant arthroscopic SLAP and rotator cuff repair: surgical technique. , 2011, The Journal of bone and joint surgery. American volume.

[93]  P. Termuhlen,et al.  Before and after resident work hour limitations: an objective assessment of the well-being of surgical residents. , 2005, Current surgery.

[94]  B. Drolet,et al.  Residents' response to duty-hour regulations--a follow-up national survey. , 2012, The New England journal of medicine.

[95]  R. Eavey,et al.  The 80-hour work guidelines and resident survey perceptions of quality. , 2006, The Journal of surgical research.

[96]  K. Horvath,et al.  Surgical training, duty-hour restrictions, and implications for meeting the Accreditation Council for Graduate Medical Education core competencies: views of surgical interns compared with program directors. , 2012, Archives of surgery.

[97]  Furman S. McDonald,et al.  Anticipated Consequences of the 2011 Duty Hours Standards: Views of Internal Medicine and Surgery Program Directors , 2012, Academic medicine : journal of the Association of American Medical Colleges.

[98]  Susie Sell,et al.  A story of success , 2009 .

[99]  J. Gould.  The impact of resident work-hour restrictions on outcomes of cardiac operations. , 2010, The Journal of surgical research.

[100]  J. Silber,et al.  Effect of work-hours regulations on intensive care unit mortality in United States teaching hospitals* , 2009, Critical care medicine.

[101]  Warren D. Widmann,et al.  A 360° Evaluation of a Night-float System for General Surgery: A Response to Mandated Work-hours Reduction , 2004 .