Limiting Orthopedic Residents' Work Hours: 15 Years of Data, No Clear Effect

The Institute of Medicine’s (IOM) sentinel report, To Err is Human: Building a Safer Health System, published to great fanfare in 1999, galvanized efforts to reduce medical error and triggered a series of systemic changes that included regulations limiting residents’ duty hours starting in 2003. Supporters of a duty hour limits in the surgical suite to 80 hours/week say that patient safety is improved. Opponents claim that limiting resident duty-hours jeopardizes resident education and preparedness. Orthopedic surgeons still debate the necessity and outcomes of limiting resident work-hours, citing this specialty’s unique requirements for competence. Clinical Orthopaedics and Related Research has published a systematic review that attempts to answer the question, “Have work-hour restrictions measurably influenced quality-of-life measures, operative and technical skill development, resident surgical education, patient care outcomes, and surgeon and resident attitudes?”

The authors, members of the U.S. Navy medical service, looked for studies addressing this subject in a broad array of search engines. They found 11 studies that met their inclusion criteria. One study was a prospective analysis. The remaining 10 were of level IV evidence (review of surgical case logs) or survey results.

Most studies reported some improvement in surgical resident quality of life; both residents and program directors reported these improvements. Residents reported more sleep and less fatigue.

The studies also found that resident and program directed believed that the work hour limitations had a negative impact on residents’ surgical operative and technical skill.

The authors found no studies that objectively assessed resident work-hour impact on orthopedic patient outcomes. Subjective data and opinions were available. Junior residents tended to see the change as positive for patient care, senior residents less so.

The authors note that high-level evidence evaluating the effect of the changes to resident work hours is needed. Future research should focus on objective measures including patient safety.