Journal of General Internal Medicine

, Volume 26, Issue 8, pp 907–919

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

  • Kathlyn E. Fletcher
  • Darcy A. Reed
  • Vineet M. Arora

DOI: 10.1007/s11606-011-1657-1

Cite this article as:
Fletcher, K.E., Reed, D.A. & Arora, V.M. J GEN INTERN MED (2011) 26: 907. doi:10.1007/s11606-011-1657-1



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.

Supplementary material

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

Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • Kathlyn E. Fletcher
    • 1
  • 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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