Impact of reduction in working hours for doctors in training on postgraduate medical education and patients' outcomes: systematic review

Moonesinghe, Ramani; Lowery, Julie C.; Shahi, Nahakul; Millen, Amy E.; Beard, Jonathan

doi:10.1136/bmj.d1580

Cited by 194 publications

(172 citation statements)

References 89 publications

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“…2 Several studies of resident education reported decreased operative experience among surgical residents after 2003, but resident burnout appears to have improved. In summary, these findings and those of another systematic review 6 suggest that the 2003 rules did not have a meaningful effect, either favorable or unfavorable, on patient safety and quality-related outcomes. Of course, this conclusion begs many questions, including whether the 2003 rules showed little impact on patient outcomes because they were too strict (causing handoff-related harms that canceled out any benefit), because they were too lax (allowing fatigued residents to continue harming patients), or because patient outcomes are inherently insensitive to duty-hour regulation (given reasonable safeguards and redundancies provided by nurses, other trainees, and faculty).…”

mentioning

confidence: 63%

The ACGME’s 2011 Changes to Resident Duty Hours: Are They an Unfunded Mandate on Teaching Hospitals?

Romano

Volpp

2011

J GEN INTERN MED

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mentioning

confidence: 63%

The ACGME’s 2011 Changes to Resident Duty Hours: Are They an Unfunded Mandate on Teaching Hospitals?

Romano

Volpp

2011

J GEN INTERN MED

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“…Further search using search terms and Boolean searches to identify research articles relevant to one or more of the themes produced 342 citations and one narrative review. 11 Search of the references of these studies identified another 14 citations. With further analysis, articles were selected wherein interventions relevant to one or more of the three themes were studied, resulting in a final selection of 56 citations Twenty-one studies analyzed transitions in, during, and after residency education; 19 studies addressed the educational effects of duty hour limits, [33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51] and 16 articles presented research on use of the competencies in teaching and assessing anesthesiology residents.…”

Section: Methodsmentioning

confidence: 99%

“…66 This has demonstrated some benefit, though studies have not shown that duty hour limits have resulted in safer care in teaching hospitals, 67,68 and in a recent review, studies were found with improved patient care outcomes, with worsening outcomes after duty hour limits, and with a number showing no change. 11 In the same review, the educational outcomes of duty hour limits were also analyzed and significant problems were found with study quality. Aside from a small number of studies that assessed performance on standardized tests, there were no data on the impact that the reduction in residents' hours would have on the acquisition of competence for independent practice, 11 potentially because true educational outcomes can be studied only years after the standards have been implemented.…”

Section: Duty Hour Limits and The Acquisition Of Competencementioning

confidence: 99%

“…11 In the same review, the educational outcomes of duty hour limits were also analyzed and significant problems were found with study quality. Aside from a small number of studies that assessed performance on standardized tests, there were no data on the impact that the reduction in residents' hours would have on the acquisition of competence for independent practice, 11 potentially because true educational outcomes can be studied only years after the standards have been implemented. As a consequence, much of the research on the effect of duty hour limits uses exposure to clinical training as a proxy for educational outcomes.…”

Section: Duty Hour Limits and The Acquisition Of Competencementioning

confidence: 99%

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Review article: Closing the research gap at the interface of learning and clinical practice

Philibert

2011

Can J Anesth/J Can Anesth

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Purpose The dialogue at the interface of education and clinical practice highlights areas of critical importance to the development of new approaches for educating anesthesiologists. The purpose of this article is to examine the literature on education and acquisition of competence in three areas relevant to the interface of learning and clinical practice, with the aim to suggest a research agenda that adds to the evidence on preparing physicians for independent practice. The three areas are: 1) transitions across the continuum of education; 2) the effect of reductions in hours of clinical training on competence; and 3) efforts to incorporate the competencies and CanMEDS roles into teaching and evaluation. Principal findings Fifty-six articles relevant to one or more of the themes were identified in the review, including 21 studies of transitions (in, during, and after residency education), 19 studies on the effects of duty hour limits on residents' acquisition of competence, and 16 articles that assessed competency-based teaching and assessment in anesthesiology. Overall, the findings suggested a relative paucity of scientific evidence and a need for research and the development of new scientific theory. Studies generally treated one of the themes in isolation, while in actuality they interact to produce optimal as well as suboptimal learning situations, while medical education research often is limited by small samples, brief follow-up, and threats to validity. This suggests a ''research gap'' where editorials and commentaries have moved ahead of an evidence base for education. Promising areas for research include preparation for care deemed important by society, work to apply knowledge about the development of expertise in other disciplines to medicine, and ways to embed the competencies in teaching and evaluation more effectively. Conclusion Closing the research gap in medical education will require clear direction for future work. The starting point, at an institution or nationally, is dialogue within the specialty to achieve consensus on some of the most pressing questions.

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“…Going forward, I think the question of what drives the choices of medical students is going to be less critical than the issue of what effect the 80-hour workweek has on the training, and ultimately the competence, of residents. Two large meta-analyses of the current literature have been somewhat contradictory and inconclusive [7,8]. In Britain, a competency-based, rather than time-limited, orthopaedic residency has been introduced [9].…”

Section: How Do We Get There?mentioning

confidence: 99%

CORR Insights: Orthopaedic Residency Applications Increase After Implementation of 80-hour Workweek

Scherl

2013

Clinical Orthopaedics &Amp; Related Research

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This CORR Insights TM is a commentary on the article ''Orthopaedic Residency Applications Increase After Implementation of 80-hour Workweek'' by Anakwenze et al. available at DOI 10.1007/s11999-013-2785-1. Where Are We Now?There has been much interest in the effects of the 80-hour workweek on resident performance, lifestyle, and education. As Anakwenze et al. note in this article, there have been conflicting data and opinions regarding whether the work-hour restrictions have achieved their intended results of decreased medical error, increased patient safety, and improved resident performance and satisfaction. Similarly, it has been hard to prove or disprove whether the 80-hour workweek has had negative ramifications on the breadth, depth, and quality of resident education and experience. Even harder to study and quantify is the question regarding whether work-hour restrictions have negatively impacted the socialization of residents, by having diluted residents' sense of ownership and responsibility for their patients, interrupting continuity of care, and fomenting a ''shiftworker'' mentality. There also has been much interest in factors that influence medical students' choice of residency. Two studies found that ''controllable lifestyle'' is the single most important factor, especially for women [5,6].Where Do We Need to Go?Anakwenze and colleagues examine the relationship between implementation of the 80-hour workweek and the number of applications to orthopaedic residencies. The results showed a 21% increase in orthopaedic residency applications after the work-hour restrictions, which the authors attribute, at least in part, to medical students' perception of an improvement in the lifestyle of orthopaedic residents. They found a concomitant 18% decrease in applications to primary care fields, and speculate that in essence, the work-hour restrictions level the playing field between residencies traditionally perceived as more strenuous, and those regarded as less demanding. Of course, choice of residency is multifactorial, as evidenced by the 24% decrease in applications to general surgery during the course of the study. We evaluated medical students in the class of 2008 at the University of Nebraska; at the beginning of each year, we asked them about their choice of residency, and contacted them again after the Match. Our response rate was low, (29%), but we found that 65% of respondents changed their minds during the course of the 4 years. A negative perception of residency lifestyle was the only statistically significant factor in the decision to make a change. Interestingly, none of the three students whoThe author certifies that he, or a member of his immediate family, has no funding or commercial association (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

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Impact of reduction in working hours for doctors in training on postgraduate medical education and patients' outcomes: systematic review

Cited by 194 publications

References 89 publications

The ACGME’s 2011 Changes to Resident Duty Hours: Are They an Unfunded Mandate on Teaching Hospitals?

The ACGME’s 2011 Changes to Resident Duty Hours: Are They an Unfunded Mandate on Teaching Hospitals?

Review article: Closing the research gap at the interface of learning and clinical practice

CORR Insights: Orthopaedic Residency Applications Increase After Implementation of 80-hour Workweek

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