title: Time-motion studies of internal medicine residents' duty hours: a systematic review and meta-analysis.
abstract: BACKGROUND
  Since the mid-1980s, medical residents' long duty hours have been under scrutiny as a factor affecting patient safety and the work environment for the residents. After several mandated changes in duty hours, it is important to understand how residents spend their time before proposing and implementing future changes. Time-motion methodology may provide reliable information on what residents do while on duty.
  
  
  OBJECTIVE
  The purpose of this study is to review all available literature pertaining to time-motion studies of internal medicine residents while on a medicine service and to understand how much of their time is apportioned to various categories of tasks, and also to determine the effects of the Accreditation Council for Graduate Medical Education (ACGME)-mandated duty hour changes on resident workflow in North America.
  
  
  METHODS
  Electronic bibliographic databases were searched for articles in English between 1941 and April 2013 reporting time-motion studies of internal medicine residents rotating through a general medicine service.
  
  
  RESULTS
  Eight articles were included. Residents spent 41.8% of time in patient care activities, 18.1% communicating, 13.8% in educational activities, 19.7% in personal/other, and 6.6% in transit. North American data showed the following changes after the implementation of the ACGME 2003 duty hours standard: patient care activities from 41.8% to 40.8%, communication activities from 19.0% to 22.3%, educational activities from 17.7% to 11.6%, and personal/other activities from 21.5% to 17.1%.
  
  
  CONCLUSIONS
  There was a paucity of time-motion data. There was great variability in the operational definitions of task categories reported in the studies. Implementation of the ACGME duty hour standards did not have a significant effect on the percentage of time spent in particular tasks. There are conflicting reports on how duty hour changes have affected patient safety. A low proportion of time spent in educational activities deserves further study and may point to a review of the educational models used.
authors.affiliation: Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Cameron W
authors.initials: CW
authors.lastname: Leafloor
authors.affiliation: Department of Medicine, University of Ottawa, Ottawa, ON, Canada ; Division of Endocrinology and Metabolism, University of Ottawa, Ottawa, ON, Canada ; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Heather A
authors.initials: HA
authors.lastname: Lochnan
authors.affiliation: Department of Medicine, University of Ottawa, Ottawa, ON, Canada ; Division of General Internal Medicine, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Catherine
authors.initials: C
authors.lastname: Code
authors.affiliation: Department of Medicine, University of Ottawa, Ottawa, ON, Canada ; Division of Endocrinology and Metabolism, University of Ottawa, Ottawa, ON, Canada ; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Erin J
authors.initials: EJ
authors.lastname: Keely
authors.affiliation: Performance Measurement and Innovation, University of Ottawa, Ottawa, ON, Canada ; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Deanna M
authors.initials: DM
authors.lastname: Rothwell
authors.affiliation: Department of Medicine, University of Ottawa, Ottawa, ON, Canada ; Division of General Internal Medicine, University of Ottawa, Ottawa, ON, Canada ; Performance Measurement and Innovation, University of Ottawa, Ottawa, ON, Canada ; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Alan J
authors.initials: AJ
authors.lastname: Forster
authors.affiliation: Department of Medicine, University of Ottawa, Ottawa, ON, Canada ; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada ; Division of Geriatric Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Allen R
authors.initials: AR
authors.lastname: Huang
keywords: residents’ duty hours; systematic review; time-motion studies; workflow