title: A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes.
abstract: 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.
authors.affiliation: *Department of Surgery, University of Toronto, Toronto, Ontario, Canada †Department of Internal Medicine, Mount Sinai Hospital, New York City, NY ‡Department of Surgery, McGill University, Montreal, Quebec, Canada §Department of Internal Medicine, University of Toronto, Toronto, Ontario, Canada ‖Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada ¶Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada **Department of Surgery, Royal Inland Hospital, Kamloops, British Columbia, Canada.
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mesh_terms: D004503:Education, Medical, Graduate / Q000379:methods*; D004521:Educational Measurement; D013502:General Surgery / Q000193:education*; D006801:Humans; D007396:Internship and Residency; D061214:Patient Safety / Q000592:standards*; D014940:Work Schedule Tolerance; D016526:Workload / Q000706:statistics & numerical data*