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Does it matter how much physician trainees work anymore?
  1. Kathlyn E Fletcher1,2,
  2. Sumant R Ranji3
  1. 1Department of Internal Medicine, Clement J. Zablocki VAMC, Milwaukee, Wisconsin, USA
  2. 2Department of Internal Medicine, Medical College of Wisconsin, Wisconsin, USA
  3. 3Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
  1. Correspondence to Dr Kathlyn E Fletcher, Medical College of Wisconsin and Milwaukee Veterans Affairs Medical Center, 5000 W. National Ave, Milwaukee, WI 53295, USA; kfletche{at}

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The restriction of working hours for physicians in training was one of the earliest and most far-reaching interventions of the patient safety movement. The US Accreditation Council for Graduate Medical Education (ACGME) implemented rules in 2003 restricting residents to 80 h of work per week and no more than 30 h of continuous duty. Subsequent regulations implemented in 20111 limited the maximum shift length for first-year trainees to 16 h and reduced continuous duty for all residents to 28 h. Other countries have implemented significantly stricter rules—the European Working Time Directive2 has limited European trainees to 48 working hours per week since 2009. These regulations directly affect >118 000 residents in the USA3 and about 40 000 junior doctors in the UK yearly, with major consequent effects on the workforce and finances of teaching hospitals and clinics.

Yet a decade of rigorous evaluation has failed to demonstrate any improvement in patient safety or clinical outcomes associated with restricting duty hours. Systematic reviews of studies of the 2003 US duty hour regulations,4 as well as well-designed studies5 of the 2011 regulations, have consistently shown that reducing duty hours did not improve patient outcomes at teaching hospitals (compared with non-teaching hospitals). The effect on education and resident well-being has been mixed at best—although some studies indicate resident perception of their education has improved, rates of burnout and depression among residents appear unaffected.6

One explanation for this finding could be that residents are still working past the point of fatigue—that is, duty hours simply have not been restricted enough or regulations have not been adequately enforced. However, no European study has demonstrated positive benefit for patients of the 48 h work week (although few studies have been performed). Another explanation could be that since outcomes such as adverse events and inpatient death are …

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