Abstract
BACKGROUND: Examining influential, highly cited articles can show the advancement of knowledge about the effect of resident physicians' long work hours, as well as the benefits and drawbacks of work hour limits. OBJECTIVE: A narrative review of 30 articles, selected for their contribution to the literature, explored outcomes of interest in the research on work hours-including patient safety, learning, and resident well-being. METHODS: Articles were selected from a comprehensive review. Citation volume, quality, and contribution to the evolving thinking on work hours and to the Accreditation Council for Graduate Medical Education standards were assessed. RESULTS: Duty hour limits are supported by the scientific literature, particularly limits on weekly hours and reducing the frequency of overnight call. The literature shows declining hours and call frequency over 4 decades of study, although the impact on patient safety, learning, and resident well-being is not clear. The review highlighted limitations of the scientific literature on resident hours, including small samples and reduced generalizability for intervention studies, and the inability to rule out confounders in large studies using administrative data. Key areas remain underinvestigated, and accepted methodology is challenged when assessing the impact of interventions on the multiple outcomes of interest. CONCLUSIONS: The influential literature, while showing the beneficial effect of work hour limits, does not answer all questions of interest in determining optimal limits on resident hours. Future research should use methods that permit a broader, collective examination of the multiple, often competing attributes of the learning environment that collectively promote patient safety and resident learning and well-being.