title: A narrative review of surgical resident duty hour limits: where do we go from here?
abstract: BACKGROUND
  Resident duty hour limits have been a point of debate among educators, administrators, and policymakers alike since the Libby Zion case in 1984. Advocates for duty hour limits in the surgical subspecialties cite improvements in patient safety, whereas opponents claim that limiting resident duty hours jeopardizes resident education and preparedness for independent surgical practice.
  
  
  METHODS
  Using orthopaedic surgery as an example, we describe the historical context of the implementation of the duty hour standards, provide a review of the literature presenting data that both supports and refutes continued restrictions, and outline suggestions for policy going forward that prioritize patient safety while maintaining an enhanced environment for resident education.
  
  
  RESULTS
  Although patient safety markers have improved in some studies since the implementation of duty hour limits, it is unclear whether this is due to changes in residency training or external factors. The literature is mixed regarding academic performance and trainee readiness during and after residency.
  
  
  CONCLUSIONS
  Although excessive duty hours and resident fatigue may have historically contributed to errors in the delivery of patient care, those are certainly not the only concerns. An overall "culture of safety," which includes pinpointing systematic improvements, identifying potential sources of error, raising performance standards and safety expectations, and implementing multiple layers of protection against medical errors, can continue to augment safety barriers and improve patient care. This can be achieved within a more flexible educational environment that protects resident education and ensures optimal training for the next generation of physicians and surgeons.
authors.forename: Peter D
authors.initials: PD
authors.lastname: Fabricant
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Dy
authors.forename: David M
authors.initials: DM
authors.lastname: Dare
authors.forename: Mathias P
authors.initials: MP
authors.lastname: Bostrom