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A Systematic Review

Kathlyn E. Fletcher, MD, MA; Willie Underwood III, MD, MS, MPH; Steven Q. Davis, MD; Rajesh S. Mangrulkar, MD; Laurence F. McMahon, Jr, MD, MPH; Sanjay Saint, MD, MPH

JAMA. 2005;294:1088-1100.

Context  The Accreditation Council for Graduate Medical Education implemented mandatory work hour limitations in July 2003, partly out of concern for residents’ well-being in the setting of sleep deprivation. These limitations are likely to also have an impact on other aspects of the lives of residents.

Objective  To summarize the literature regarding the effect of interventions to reduce resident work hours on residents’ education and quality of life.

Data Sources  We searched the English-language literature about resident work hours from 1966 through April 2005 using MEDLINE, EMBASE, and Current Contents, supplemented with hand-search of additional journals, reference list review, and review of abstracts from national meetings.

Study Selection  Studies were included that assessed a system change designed to counteract the effects of resident work hours, fatigue, or sleep deprivation; included an outcome directly related to residents; and were conducted in the United States.

Data Extraction  For each included study, 2 investigators independently abstracted data related to study quality, subjects, interventions, and findings using a standard data abstraction form.

Data Synthesis  Fifty-four articles met inclusion criteria. The interventions used to decrease resident work hours varied but included night and day float teams, extra cross-coverage, and physician extenders. Outcomes included measures of resident education (operative experience, test scores, satisfaction) and quality of residents’ lives (amount of sleep, well-being). Interventions to reduce resident work hours resulted in mixed effects on both operative experience and on perceived educational quality but generally improved residents’ quality of life. Many studies had major limitations in their design or conduct.

Conclusions  Past interventions suggest that residents’ quality of life may improve with work hour limitations, but interpretation of the outcomes of these studies is hampered by suboptimal study design and the use of nonvalidated instruments. The long-term impact of reducing resident work hours on education remains unknown. Current and future interventions should be evaluated with more rigorous methods and should investigate links between residents’ quality of life and quality of patient care.

Author Affiliations: Department of Internal Medicine, Clement J. Zablocki VA Medical Center/Medical College of Wisconsin, Milwaukee (Dr Fletcher); Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Mich (Drs Underwood and Saint); Departments of Urology (Dr Underwood) and Internal Medicine (Drs Mangrulkar and McMahon), University of Michigan Medical School, Ann Arbor; Department of Internal Medicine, University of Chicago Pritzker School of Medicine, Chicago, Ill (Dr Davis).

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