Do working hour limitations have an impact on surgical training: a narrative review

Background and Objective: During the last 20 years working hour limitations (WHL) for medical doctors have been introduced worldwide. Especially for surgical specialties these might pose a risk, as residents' training time is significantly reduced. Also, a higher amount of shift rotations is required as maximum continuous working hours are reduced. The aim of this review was to analyze available literature regarding the impact of WHL on residents' education, patient safety and quality of life. Methods: For this narrative review, a syntax was predefined and used to search MEDLINE, PubMed Central and Bookshelf from database inception until February 13th 2022. The syntax delivered 91 publications, with 42 being included in this review (49 excluded due to not addressing the topic of this review or being letters/comments/abstracts). Only manuscripts addressing surgical residents were included. Publications were assessed by two authors independently. Key Content and Findings: Perceived resident education was mostly negatively impacted by WHL with no publication reporting of positive perceived effects. Three publications, analyzing objective measurement of resident education, showed an increase in test scores or at least no change after WHL. Decreased operative case load was reported by 50% of publications, no change by 29% and an increase by 21%. A trend for shift of work load from younger residents towards more senior ones was found. No study reported improved perceived patient safety after WHL. Impact on objectively measured patient safety remained inconclusive with a trend towards impaired patient safety. Most included publications showed positive effects of WHL on residents' quality of life, well-being and time available for family/education. Conclusions: Definitive impacts of WHL on residents' education and patient safety remain inconclusive, although a trend towards reduced operative case load can be seen. Patient safety may suffer due to reduced operative experience, impaired continuity of care, more shift changes and sign-outs as possible sources of errors. Nevertheless, residents' quality of life improved with WHL. Under current WHL, measures have to be taken to facilitate adequate resident education, thereby keeping patient safety high but without prolonging training programs.