title: Conceptual frameworks in the study of duty hours changes in graduate medical education: a review.
abstract: OBJECTIVE
  Conceptual frameworks are approaches to a research problem that specify key entities and their relationships. The 2009 Institute of Medicine (IOM) report on resident duty hours, subsequent studies, and published responses to the report present a variety of conceptual frameworks for the study of the impact of duty hours regulations. The authors sought to identify and describe these conceptual frameworks and their implications.
  
  
  METHODS
  The authors reviewed the IOM report and articles in both peer-reviewed and non-peer-reviewed literature for the period January 2008 through April 2010, identified using multiple electronic databases including PubMed, EMBASE, CINAHL, BEME, and PsycInfo. Studies that explicitly described or argued for the effect of resident duty hours on any other outcome, as judged by consensus of multiple reviewers, were included. The authors selected 239 of 858 studies reviewed. Several of the authors reviewed articles to identify conceptual frameworks used implicitly or explicitly to describe the relationship between duty hours (or duty hours regulations) and outcomes. Identification was by consensus.
  
  
  RESULTS
  Twenty-three conceptual frameworks were identified. Several made contradictory predictions about the impact of duty hours regulations on patient outcomes, resident education, and other key outcomes.
  
  
  CONCLUSIONS
  The concept of duty hours itself is contested, and little attention has been paid to the nature and intensity of the activities that occupy residents' hours. Much research focuses on isolated outcomes of duty hours changes without considering mediation or moderation. More studies are needed to define trade-offs between outcomes and the value society places on these trade-offs.
authors.affiliation: Department of Medical Education, University of Illinois at Chicago, Chicago, Illinois 60612, USA. alansz@zzuic.edu
authors.forename: Alan
authors.initials: A
authors.lastname: Schwartz
authors.forename: Cleo
authors.initials: C
authors.lastname: Pappas
authors.forename: Philip G
authors.initials: PG
authors.lastname: Bashook
authors.forename: Georges
authors.initials: G
authors.lastname: Bordage
authors.forename: Marcia
authors.initials: M
authors.lastname: Edison
authors.forename: Bharati
authors.initials: B
authors.lastname: Prasad
authors.forename: Valerie
authors.initials: V
authors.lastname: Swiatkowski
mesh_terms: D004503:Education, Medical, Graduate / Q000458:organization & administration*; D006801:Humans; D010561:Personnel Staffing and Scheduling / Q000458:organization & administration*; D016526:Workload