Intended for healthcare professionals

CCBYNC Open access

Impact of reduction in working hours for doctors in training on postgraduate medical education and patients’ outcomes: systematic review

BMJ 2011; 342 doi: (Published 22 March 2011) Cite this as: BMJ 2011;342:d1580
  1. S R Moonesinghe, consultant and honorary senior lecturer in anaesthesia1, director2,
  2. J Lowery, specialty trainee, anaesthetics3,
  3. N Shahi, specialty trainee, surgery4,
  4. A Millen, specialty trainee, surgery5,
  5. J D Beard, honorary professor of surgical education and consultant in vascular surgery6
  1. 1University College Hospital, London NW1 6BU, UK
  2. 2Surgical Outcomes Research Centre, Joint UCL/UCLH Comprehensive Biomedical Research Centre, London WC1E 6BT
  3. 3Centre for Anaesthesia, Central London School of Anaesthesia, London NW1 2BU
  4. 4Department of Surgery, Diana Princess of Wales Hospital, Grimsby DN33 2BA
  5. 5Department of Vascular Surgery, Doncaster Royal Infirmary, Doncaster DN2 5LT
  6. 6Department of Surgery, Northern General Hospital, Sheffield S5 7AU
  1. Correspondence to: S R Moonesinghe ramani.moonesinghe{at}
  • Accepted 24 January 2011


Objectives To determine whether a reduction in working hours of doctors in postgraduate medical training has had an effect on objective measures of medical education and clinical outcome.

Design Systematic review.

Data sources Medline, Embase, ISI Web of Science, Google Scholar, ERIC, and SIGLE were searched without language restriction for articles published between 1990 and December 2010. Reference lists and citations of selected articles.

Study selection Studies that assessed the impact of a change in duty hours using any objective measure of outcome related to postgraduate medical training, patient safety, or clinical outcome. Any study design was eligible for inclusion.

Results 72 studies were eligible for inclusion: 38 reporting training outcomes, 31 reporting outcomes in patients, and three reporting both. A reduction in working hours from greater than 80 hours a week (in accordance with US recommendations) does not seem to have adversely affected patient safety and has had limited effect on postgraduate training. Reports on the impact of European legislation limiting working hours to less than 56 or 48 a week are of poor quality and have conflicting results, meaning that firm conclusions cannot be made.

Conclusions Reducing working hours to less than 80 a week has not adversely affected outcomes in patient or postgraduate training in the US. The impact of reducing hours to less than 56 or 48 a week in the UK has not yet been sufficiently evaluated in high quality studies. Further work is required, particularly in the European Union, using large multicentre evaluations of the impact of duty hours’ legislation on objective educational and clinical outcomes.


  • Contributors: SRM and JDB were responsible for the conception and design of the study. SRM had principal responsibility for analysing and interpreting the data and for drafting the article, revisions, and final approval. JL, NS, and AM contributed to analysis and interpretation of the data. JDB contributed to drafting, revision, and final approval of the article. SRM is the guarantor.

  • Funding: SRM works within the UCL/UCLH Joint Comprehensive Biomedical Research Centre, which received a proportion of funding from the National Institute for Health Research’s funding scheme. Part of this work was conducted while SRM was a National Institute for Academic Anaesthesia (NIAA) Research Fellow, supported by a grant awarded to the NIAA’s Health Services Research Centre by the Frances and Augustus Newman Foundation. This study was not commissioned and no project specific funding was received. The funders had no role in the study design, data collection, analysis, and interpretation; writing the manuscript; or the decision to submit the research for publication.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Data sharing: No additional data available.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

View Full Text