Journal of General Internal Medicine

, Volume 26, Issue 8, pp 907–919 | Cite as

Patient Safety, Resident Education and Resident Well-Being Following Implementation of the 2003 ACGME Duty Hour Rules

  • Kathlyn E. FletcherEmail author
  • Darcy A. Reed
  • Vineet M. Arora



The ACGME-released revisions to the 2003 duty hour standards.


To review the impact of the 2003 duty hour reform as it pertains to resident and patient outcomes.

Data Sources

Medline (1989–May 2010), Embase (1989–June 2010), bibliographies, pertinent reviews, and meeting abstracts.

Study Selection

We included studies examining the relationship between the pre- and post-2003 time periods and patient outcomes (mortality, complications, errors), resident education (standardized test scores, clinical experience), and well-being (as measured by the Maslach Burnout Inventory). We excluded non-US studies.

Data Extraction

One rater used structured data collection forms to abstract data on study design, quality, and outcomes. We synthesized the literature qualitatively and included a meta-analysis of patient mortality.


Of 5,345 studies identified, 60 met eligibility criteria. Twenty-eight studies included an objective outcome related to patients; 10 assessed standardized resident examination scores; 26 assessed resident operative experience. Eight assessed resident burnout. Meta-analysis of the mortality studies revealed a significant improvement in mortality in the post-2003 time period with a pooled odds ratio (OR) of 0.9 (95% CI: 0.84, 0.95). These results were significant for medical (OR 0.91; 95% CI: 0.85, 0.98) and surgical patients (OR 0.86; 95% CI: 0.75, 0.97). However, significant heterogeneity was present (I2 83%). Patient complications were more nuanced. Some increased in frequency; others decreased. Outcomes for resident operative experience and standardized knowledge tests varied substantially across studies. Resident well-being improved in most studies.


Most studies were observational. Not all studies of mortality provided enough information to be included in the meta-analysis. We used unadjusted odds ratios in the meta-analysis; statistical heterogeneity was substantial. Publication bias is possible.


Since 2003, patient mortality appears to have improved, although this could be due to secular trends. Resident well-being appears improved. Change in resident educational experience is less clear.


Maslach Burnout Inventory Unadjusted Odds Ratio Medical Education Research Small Study Effect Study Team Member 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Author contributions

Dr. Fletcher had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the analysis.

Study concept and design: Fletcher, Reed, Arora

Acquisition of data: Fletcher, Reed, Arora

Analysis and interpretation of data: Fletcher, Reed, Arora, Jackson

Drafting of the manuscript: Fletcher

Critical revision of the manuscript for important intellectual content: Fletcher, Reed, Arora

Statistical analysis: Fletcher, Reed, Arora, Jackson

Obtained funding: Fletcher, Reed, Arora

Administrative, technical, or material support: Fletcher, Reed, Arora

Study supervision: Fletcher, Reed, Arora

Funding Support

This study was funded by a grant from the Accreditation Council of Graduate Medical Education.

Role of the Sponsor

The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Financial Disclosures

Dr. Fletcher reports receiving funding from the VA HSRD and also from NCI. Dr. Reed reports receiving funding from the ABIM Foundation. Dr. Arora reports receiving grant funding from the ABIM Foundation, the ACP Foundation, the Agency for Healthcare Research and Quality, and the National Institutes of Aging. Dr. Fletcher was a reviewer for the Institute of Medicine Report on Resident Duty Hours: Sleep, Supervision and Safety. Dr. Fletcher served voluntarily on the ACGME Committee on Innovation, Learning, and Education. Dr. Arora has provided testimony on duty hours to the Institute of Medicine Committee on Optimizing Graduate Medical Trainee Hours and Work Schedules to Improve Patient Safety and to the ACGME Duty Hours Congress as a representative of the American College of Physicians. Drs. Arora and Reed are members of the Association of Program Directors of Internal Medicine.

Additional Contributions

We wish to thank Jessica Schmidt and Andrea Bruckbauer at the Milwaukee VAMC, Alexis Dye, MS, Sherrie Smaxwill and Mark Oium, MS, at the Medical College of Wisconsin, Katya Papatla at Duke University, Patricia Erwin and Kate Featherstone at the Mayo Clinic College of Medicine, and Meryl Prochaska, BA, and Diane Daviera, BS, at the University of Chicago, and Emily Chiu at the University of Michigan for their excellent research assistance. We also wish to thank Jack Littrell, MS, for his assistance with database creation and management, and DeWitt Baldwin, MD, at the ACGME for his assistance with obtaining funding. We are grateful to Jeffrey Jackson, MD MPH, for conducting the meta-analysis and to Dr. Monica Lypson, MD, for her review of the bibliography. Ms. Bruckbauer was a Milwaukee VAMC employee while this project was underway and was also paid through the ACGME grant. Ms. Schmidt is an employee of the Milwaukee VAMC and was also paid through the ACGME grant. Ms. Papatla was paid through the ACGME grant. Ms. Dye, Mr. Oium, Ms. Smaxwill, and Mr. Littrell are paid employees at the Medical College of Wisconsin and volunteered to help with this project. Ms. Erwin and Featherstone are paid employees of the Mayo Clinic College of Medicine. Ms. Prochaska and Daviera are paid employees of the University of Chicago, and Ms. Chiu was paid by the ACGME grant.

Supplementary material

11606_2011_1657_MOESM1_ESM.doc (168 kb)
ESM 1 Study quality and outcomes assessed for all included studies (DOC 168 kb)


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Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • Kathlyn E. Fletcher
    • 1
    Email author
  • Darcy A. Reed
    • 2
  • Vineet M. Arora
    • 3
  1. 1.Department of MedicineMilwaukee VAMC/ Medical College of WisconsinMilwaukeeUSA
  2. 2.Department of MedicineMayo Clinic College of MedicineRochesterUSA
  3. 3.Department of MedicineUniversity of Chicago, Pritzker School of MedicineChicagoUSA

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