The impact of shortening shifts of physicians during their residency on patients and physicians : A systematic review and meta-analysis

Abstract

Background: Prolonged shifts in residency contribute to physician fatigue, cognitive decline, and increased medical errors. This systematic review and meta-analysis evaluate how reducing shift length affects patient-physician safety, physician well-being, and residency training, addressing the ongoing challenge of balancing resident welfare, patient outcomes, and educational standards across varied implementation settings.

Methods: A comprehensive search of PubMed, EMBASE, The Cochrane Library, Google Scholar, and opengrey.eu was performed from database inception to January 2024. Eligible studies assessed the effects of duty hour limitations (≤ 24 h) on clinical, educational, or systemic outcomes. Both randomized controlled trials and observational studies were included. Meta-analyses used random-effects models. Risk of bias was assessed with RoB 2.0 and ROBINS-I tools. Subgroup analyses were performed by specialty, shift duration, and publication period. Sensitivity analyses excluded studies with extended timeframes.

Results: A total of 108 studies (8 RCTs, 100 observational) were included. Shift shortening was associated with improved resident well-being, including reduced fatigue and work-life balance. Patient safety remained stable, with a significant reduction in 30-day mortality for shifts ≤ 16 h (pooled OR 0.84, 95% CI 0.79-0.89). No significant effect on complications or adverse events was observed. Operative experience showed mixed results, with a non-significant reduction in case volume (pooled std. mean difference 0.65, 95% CI -0.04 to 1.34, P = 0.07), while test scores exhibited minimal changes. Effect directions remained consistent across publication periods. High heterogeneity and risk of bias were observed across most included studies.

Conclusions: Shortening shifts to 24 h or less appears to improve residents' satisfaction and work-life balance while maintaining patient safety outcomes. Educational outcomes were mixed; operative experience was preserved in some settings, while effects on non-surgical training remain less clear. These findings underscore the importance of tailoring reforms to specialty needs and training contexts. Future research should examine unstudied outcomes, such as residency attrition or shifts to less demanding specializations, and system-wide implementation costs. A stepped wedge cluster randomized trial is recommended for future policy evaluations.

Systematic review registration: PROSPERO CRD42023390197.

Keywords: Cognitive impairment; Duty hours; Fatigue; Patient safety; Physician safety; Residency quality; Resident physician shifts; Shift reforms; Shift shortening; Work-hour limitations.

Fig. 1

PRISMA flow diagram. This figure illustrates the flow of information through the different phases of the systematic review. It maps out the number of records identified, included and excluded, and the reasons for exclusions

Fig. 2

Forest plot describing the association of shift shortening and patient 30-day mortality. This forest plot displays the association between shortened shifts for medical residents and patient 30-day mortality rates across various studies

Fig. 3

Forest plot describing the association of shortening of shifts to 16 h or less and patient 30-day mortality. This forest plot specifically focuses on the impact of limiting shifts to 16 hours or less on patient 30-day mortality

Fig. 4

Forest plot describing the association of shift shortening and non-surgical complications and adverse events. This forest plot displays the association between shift shortening and the occurrence of non-surgical complications and adverse events in patients

Fig. 5

Forest plot describing the association of shift shortening and surgical complications and adverse events per type of specialty. This forest plot displays the association between shift shortening and the occurrence of surgical complications and adverse events in patients, across various medical specialties

Fig. 6

Forest plot describing the association of shortening of shifts and operative experience in general surgery residents (measured as mean number of operations per resident). This forest plot displays the association between shift shortening and operative experience of general surgery residents, measured as the mean number of operations per resident