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Review | Clinician's Corner

Effects of Work Hour Reduction on Residents’ Lives:  A Systematic Review FREE

Kathlyn E. Fletcher, MD, MA; Willie Underwood, MD, MS, MPH; Steven Q. Davis, MD; Rajesh S. Mangrulkar, MD; Laurence F. McMahon, MD, MPH; Sanjay Saint, MD, MPH
[+] Author Affiliations

Author Affiliations: Department of Internal Medicine, Clement J. Zablocki VA Medical Center/Medical College of Wisconsin, Milwaukee (Dr Fletcher); Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Mich (Drs Underwood and Saint); Departments of Urology (Dr Underwood) and Internal Medicine (Drs Mangrulkar and McMahon), University of Michigan Medical School, Ann Arbor; Department of Internal Medicine, University of Chicago Pritzker School of Medicine, Chicago, Ill (Dr Davis).

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JAMA. 2005;294(9):1088-1100. doi:10.1001/jama.294.9.1088.
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Published online

Context The Accreditation Council for Graduate Medical Education implemented mandatory work hour limitations in July 2003, partly out of concern for residents’ well-being in the setting of sleep deprivation. These limitations are likely to also have an impact on other aspects of the lives of residents.

Objective To summarize the literature regarding the effect of interventions to reduce resident work hours on residents’ education and quality of life.

Data Sources We searched the English-language literature about resident work hours from 1966 through April 2005 using MEDLINE, EMBASE, and Current Contents, supplemented with hand-search of additional journals, reference list review, and review of abstracts from national meetings.

Study Selection Studies were included that assessed a system change designed to counteract the effects of resident work hours, fatigue, or sleep deprivation; included an outcome directly related to residents; and were conducted in the United States.

Data Extraction For each included study, 2 investigators independently abstracted data related to study quality, subjects, interventions, and findings using a standard data abstraction form.

Data Synthesis Fifty-four articles met inclusion criteria. The interventions used to decrease resident work hours varied but included night and day float teams, extra cross-coverage, and physician extenders. Outcomes included measures of resident education (operative experience, test scores, satisfaction) and quality of residents’ lives (amount of sleep, well-being). Interventions to reduce resident work hours resulted in mixed effects on both operative experience and on perceived educational quality but generally improved residents’ quality of life. Many studies had major limitations in their design or conduct.

Conclusions Past interventions suggest that residents’ quality of life may improve with work hour limitations, but interpretation of the outcomes of these studies is hampered by suboptimal study design and the use of nonvalidated instruments. The long-term impact of reducing resident work hours on education remains unknown. Current and future interventions should be evaluated with more rigorous methods and should investigate links between residents’ quality of life and quality of patient care.

Figures in this Article

Concern about negative effects of sleep deprivation on residents’ well-being is one of several factors behind the mandatory work hour restrictions instituted by the Accreditation Council for Graduate Medical Education (ACGME) in July 2003.1 Two groups promoting such restrictions represented residents2 and medical students.3 While also concerned about patient safety, these groups specifically called attention to the effect of long work hours on residents’ lives by lobbying Congress and petitioning the Occupational Safety and Health Administration to modify resident work hours.4 However, some residency training faculty remain apprehensive about what effect the new work hour restrictions will have on education.5

Sleep deprivation affects myriad aspects of residents’ lives. In observational studies, safety issues such as risk for automobile crashes have been related to prolonged work shifts.6 Issues of well-being such as mood,7,8 stress,9,10 and relationship-related stress10 have been linked to sleep deprivation, as have educational outcomes such as worse performance on simulated tasks11,12 and standardized tests.1315 It is possible that residents’ well-being, task performance, and test taking will improve in the short term with fewer work hours, but the long-term impact of these changes is unknown.

We have described a conceptual model that balances the potential benefits and drawbacks of continuity of care with those of interventions to decrease resident work hours.16 In a systematic review of the impact of decreasing resident work hours on patient safety,17 we found insufficient evidence to fully inform this issue because the interventions were variable, the study quality suboptimal, and the results conflicting, with some indicators remaining unchanged, some improved, and some worsened after change.

Quiz Ref IDWe now consider 2 broader areas of resident education and quality of life. Resident education includes resident performance (eg, operative cases and test scores) and resident satisfaction. Quality of life includes resident health and cognitive function. We performed a systematic review of the literature to describe the impact of interventions (mostly made before the ACGME restrictions) intended to decrease resident work hours on residents’ educational experience and quality of life.

Data Sources

We initially searched the English-language literature for studies about resident work hours for the period 1966 to mid 2002 using MEDLINE, PREMEDLINE, EMBASE, and Current Contents. In April 2005, we updated the MEDLINE and EMBASE searches using the same strategy. We used combinations of terms related to work (workload, work schedule, workschedule tolerance, fatigue, mental fatigue, work hours, personnel staffing and scheduling), sleep (sleep; sleep deprivation; sleep disorders; sleep disorder, circadian rhythm; chronobiology), and residency (education, medical, graduate; internship and residency; nightfloat).

We hand-searched journals that are not indexed for certain years between 1966 and 2002 (Medical Teacher, Medical Education, the British Journal of Medical Education, and Teaching and Learning in Medicine). We examined the reference lists of all articles included in the review as well as those of review articles. We reviewed the abstracts and papers from the Association of American Medical Colleges Research in Medical Education for the years 1989-2004 and the Society of General Internal Medicine national meeting for the years 1989-2005. Whenever possible, we corresponded with the authors of the abstracts to clarify questions. Finally, 3 studies that were too recent to be indexed at the time of the search were identified at the time of their publication.

Study Selection

Inclusion criteria were assessment of a system change designed to counteract the effects of work hours, fatigue, or sleep deprivation; an outcome directly related to residents; and study completion in the United States.

Starting with more than 1200 citations for 1966-2002 and 790 from 2002-2005, we reviewed the abstracts of all relevant articles (Figure). Of those, 528 were abstracts or titles for articles appropriate for detailed review to determine if they met inclusion criteria. Articles eliminated without full review were either not research reports, on the wrong topic, or were editorials. Two authors independently reviewed each article from the first search to ascertain if they met inclusion criteria. Disagreement was resolved by consensus, with input from a third author for 1 article. The articles from the 2002-2005 search were reviewed by 1 author using the same inclusion criteria.

Of the 528 articles reviewed, 86 described relevant interventions. We excluded 21 studies that were not performed in the United States and 11 studies that assessed only patient outcomes. We report on 54 studies that evaluated interventions to decrease resident work hours in the United States and assessed an outcome related to residents’ lives.

Data Abstraction

The data from each included article were abstracted by 2 of 3 authors. We used a standardized abstraction form that included number of subjects, presence or absence of a control group, study design, outcomes, and methodological concerns. All disagreements were resolved by consensus. We were able to contact authors from 4 of the 6 studies for which we needed clarification.

Assessment of Study Quality

For study designs other than surveys, we used a modification of the US Preventive Services Task Force (USPSTF)18 criteria to judge the study quality (eTable 3). The USPSTF uses a hierarchy of overall study design as well as a rating of the internal validity. In that hierarchy, well-done randomized controlled trials constitute the highest tier of evidence, while nonrandomized controlled trials, case-control studies, and cohort studies provide second-tier evidence. All but 1 of the studies we identified provided second-tier evidence by these standards.

For survey studies, we developed criteria (eTable 4) based on several resources.1921 A few studies included both a survey component and a nonsurvey component. In those instances, we rated each component using the appropriate set of criteria. At least 1 author rated the quality of each included study, and all disagreements were resolved by consensus.

Results of the published studies are summarized in the Tables. Comprehensive details about each published study and the abstracts, as well as detailed methodological evaluations, are available in the online eTables.

Internal Medicine

Twelve studies addressing internal medicine residents were included, with study quality ranging from poor to good (Table 1).

Table Graphic Jump LocationTable 1. Summary of Study Designs, Interventions, and Outcomes of Internal Medicine Programs

Education. Resident education was assessed entirely by survey and interview studies. Issues studied included the impact of new systems on education, professionalism, and satisfaction.

Residents rated the impact of fatigue on learning as better with a nontraditional float system compared with a traditional every-fourth-night call system (on a 1-7 scale with 1 = strongly agree that learning is impaired by fatigue: 3.4 vs 2.0, respectively).28 In this system, an intern floated with a team for 5 days before moving to a different team.

Professionalism was rated in 2 studies. In one,23 faculty thought that residents had developed a “shift-work”mentality after a night float was added, although residents disagreed. In the other,32 residents reported maintaining their sense of responsibility for their patients after night float was added. (Night float is a system that has 1 or more residents work shifts at night to cover some part of patient care responsibilities. These could include taking calls about patients already in the hospital and/or admitting new patients. If new patients are admitted by night float residents, another team assumes responsibility in the morning.)

In a survey study that included factor analysis, satisfaction with a factor representing faculty, learning, and environment decreased from 3.81 to 2.85 (on a 1-5 scale with 5 as the most positive score) after changes in the intensive care unit and elective rotations significantly increased call nights for second- and third-year residents.30 This factor included items on feedback, career counseling, faculty teaching, personal support from faculty, and clarity of expectations. In another study,31 81% of program directors agreed that morale was improved when night float systems were used.

Quality of Life. Issues addressed included the impact of new systems on resident health (amount of sleep and mood), number of hours worked, and cognitive function.

In one program,24 the addition of a night float system resulted in residents sleeping 2 hours more on-call when the night float resident was on duty.24 In addition, weekly work hours decreased significantly from 91 to 84. In a different program with a night float, residents did not sleep more, but they did have better sleep efficiency.27 However, no significant difference was detected on tests of attention between the residents who had night float coverage and those who did not.

With a new system that decreased the length of the longest shift from 30 hours to 16 hours and added another intern to intensive care unit rotations, residents slept about 6 hours per week more than with the traditional schedule.26 Weekly work hours decreased significantly from 85 to 65, and nighttime attentional failures as measured by electroencephalogram decreased significantly for those working the intervention schedule compared with the traditional schedule (0.33 vs 0.69 per hour, respectively).

Having night float coverage did not significantly change anxiety, hostility, or depression scores in one program.25 In addition, no difference was demonstrated between residents on night float and residents on a normal schedule when their fine motor skills, attention, concentration, memory, or concept formation were tested. In another study, residents felt less stressed and depressed after a night float and other changes were made (on a 1-5 scale with 5 = strongly agree that the resident felt stressed or depressed: 2.77 before vs 1.87 after changes).29 However, further changes that increased call nights for the second- and third-year residents resulted in increased stress levels in that same program.30

Obstetrics/Gynecology

We found 6 studies that evaluated obstetrics/gynecology residents (Table 2). Study quality ranged from poor to moderate.

Table Graphic Jump LocationTable 2. Summary of Study Designs, Interventions, and Outcomes of Obstetrics/Gynecology Programs

Education. The issues studied included the impact of interventions on perception of education in general, operative experience, test scores, perception of ambulatory experience, and satisfaction.

Quiz Ref IDOne study compared fourth-year residents before and after restructuring teams (including the formation of a night float system) and found that on average each resident performed significantly fewer laparoscopies (41.6 vs 26.4 per year, respectively), primary cesarean deliveries (48 vs 25 per year, respectively), vaginal births after cesarean deliveries (10.1 per year vs 1.8 per year, respectively), and several other procedures.35 The total number of cesarean deliveries and sterilization procedures per resident per year significantly increased (from 48 to 78.2 and from 15.6 to 37.8, respectively).35 When resident procedure volume was divided by institutional volume, residents performed a significantly smaller percentage of the total abdominal hysterectomies, hysteroscopies, primary cesarean deliveries, and vaginal births after cesarean deliveries after the intervention; sterilizations remained increased.

In a program that added a physician assistant, midwives, and a night float, the investigators demonstrated no change in the number of major procedures performed by the resident service before and after the changes.38 Perceived education was rated as improved in that program. However, a nonstatistically significant decline in in-service test scores was demonstrated.

Another program instituted a night team and sent residents home post-call to decrease work hours, and a slight upward trend in in-service scores was seen after those changes.36 However, significance testing was not performed.

Two cross-sectional survey studies assessed perceived operative experience and satisfaction after interventions to decrease hours. In the first study,37 72% of residents reported unchanged surgical experience after changes that included increased number of faculty, physician assistant and midwife coverage, and the addition of a night float system. Eight-six percent of residents rated their satisfaction as improved, and 47% and 53% rated their obstetrical experience as improved or unchanged, respectively. However, 35% and 58% rated their ambulatory experience as unchanged or worse, respectively, after the interventions.

In the second study,40 a survey of program directors who had implemented night float systems found that the directors of most New York programs rated surgical and ambulatory experience between impaired and unchanged, while non–New York program directors thought that both improved. Although all program directors rated resident satisfaction as improved, the directors from non–New York programs rated resident satisfaction as significantly greater than did those from New York programs. The authors attributed the more negative perceptions held by the New York programs to the rigid rules of Code 40534 to which the New York programs had to comply.

Quality of Life. No change in resident stress was noted in a program after the addition of a night rotation,39 but neither was there a change in perceived resident support after the change. After the intervention, however, residents perceived less peer resentment of their own pregnancies.39

Pediatrics

We found a total of 7 studies that evaluated pediatrics training, with quality ranging from poor to moderate (Table 3)

Table Graphic Jump LocationTable 3. Summary of Study Designs, Interventions, and Outcomes of Pediatrics Programs

Education. Impact on education was addressed in these studies. Quiz Ref IDOne pediatrics program instituted an evening continuity clinic once monthly for residents so that post-call afternoon clinics could be avoided.44 Eighty-six percent of residents felt that they could learn better and 82% thought that they could display more empathy during the evening clinics as compared with post-call clinics. They also felt that the evening clinics contributed more to their primary care education than would other educational activities that could be scheduled instead of cancelled post-call clinics, such as visits to homeless shelters.

A statewide survey that was conducted before implementation of Code 405 in New York, and repeated for several years, showed that by the third year after the regulations, residents’ rating of time available for reading was not statistically significantly different than before implementation (15% agreed that they had enough time for reading in the year before Code 405 was enacted compared with 26%, 31%, and 22% in the next 3 years).46 Residents also thought that lack of sleep interfered with their clinical judgment less in the first 3 years following enactment of Code 405 compared with previous years; however, by the last year of the survey, this item was rated no differently than in the year prior to Code 405 enactment. The authors suggested that the lack of difference in later years could have been due to reduced enforcement of the rules over time.

Quality of Life. Issues addressed by these studies included resident health (amount of sleep and mood) and cognitive function. Two studies were conducted in the same program to assess the impact of a night float rotation.41,42 When residents who worked as the night float tracked their sleep using diaries, they reported less sleep when acting as the night float than when on a typical ward rotation.42 In contrast, a study of the same residents using a survey rather than diaries demonstrated no difference in the amount of sleep between the 2 conditions.41 More residents reported that falling asleep was difficult and that there were more sleep interruptions while on night float than during regular rotations.41 Residents expressed more depressed feelings while on night float41 and scored lower on vigor and higher on fatigue in the Profile of Mood States.42 Cognitive function tests of alertness and attention were no different when performed in night float residents vs residents on regular rotations.42

In another program with night float coverage 5 nights per week, sleep for senior residents increased when night float coverage was available compared with nights without coverage.45 The amount of sleep for interns did not change regardless of night float coverage.

Surgery

Twenty-five studies assessed the impact of interventions to reduce work hours on surgical residents. Study quality ranged from poor to moderate (Table 4).

Table Graphic Jump LocationTable 4. Summary of Study Designs, Interventions, and Outcomes of Surgery Programs

Education. Issues addressed in these studies included perceived impact on education in general and impact on operative experience. In a statewide survey of surgical residents to evaluate the impact of Code 405 in New York, 22% of residents thought that training had improved and 35% thought it had been harmed.71 Residents reported that time to read increased in a program that incorporated 12-hour night shifts and home call to decrease hours,68 as did residents in a program that changed to day teams and night teams.57

Three programs demonstrated an increase in operative experience after interventions.48,60,65 In the highest-quality study of this group,48 a program that added a night float and weekend cross-coverage reported significantly more cases for the chief residents as a group (an average of 1015 cases per year for the 3 years before and 1116 for the 3 years after the changes).48 Another program added health technicians to the surgical service, resulting in each resident spending an average of 9.8 hours per week in the operating room after the intervention compared with 3.3 hours per week before.65

On the other hand, 2 studies suggested that operative experience may not change with interventions to reduce resident hours. In the first, residents left the hospital on post-call mornings, and the number of operative cases did not change before vs after the changes.66 The findings of a national study of surgical programs for the 2 years prior to the ACGME work hour rules63 suggested that the number of operative cases for chief residents did not vary depending on whether the program had in place an 80-hour per week model, or whether it had experimented with changes to comply with the impending ACGME work hours rules.

Finally, 3 studies suggested that operative cases may actually decrease with certain interventions.51,57,70 In the highest-quality study of this group,57 after the formation of day and night teams, fourth-year residents performed significantly fewer cases (270 per year vs 207 per year). The numbers for second- and third-year residents also showed a downward trend, while first- and fifth-year resident experience remained the same.

Quality of Life. Issues assessed included quality of life in general, resident health (sleep, well-being, and mood), and number of hours worked. In the 5 studies that measured resident work hours after interventions, they were decreased.51,52,57,58,65 In another study, residents reported a perceived decrease in hours in the hospital and workload after physician assistants were added to the surgical team.69

Eighty-five percent of residents agreed that quality of life improved after night float was added and cross-coverage was increased in 1 program.48 In a statewide survey,71 66% of New York residents thought that quality of life improved after Code 405. In a program that surveyed residents before and after addition of night shifts and home call,68 residents reported improved quality of life (on a 1-5 scale with 5 = strongly agree: 3.1 vs 3.6, respectively), adequate rest more frequently (2.3 vs 3.0, respectively), and more time for family (2.1 vs 2.9, respectively) and for socializing (2.4 vs 3.1, respectively).

Residents’ spouses reported that residents were more available for family events after separate night and day teams were instituted.57 Residents in that program also reported decreased fatigue after the interventions. Quiz Ref IDIn a study designed to increase protected time for sleep or reading at night, a “communication notebook” for the nurses to record nonurgent issues for the interns was instituted.54 This resulted in more perceived sleep on call, a fewer number of pages at night (86 pages/week before vs 53 after), and more nights without any pages between 1 AM and 5 AM (25% before vs 100% after).

Family Medicine, Psychiatry, and Radiology

Family medicine, psychiatry, and radiology had only 4 studies between them, and all were survey studies of fair to moderate quality (Table 5). In a cross-sectional survey of family medicine program directors,73 88% reported increased resident satisfaction with night float, 90% thought that resident alertness improved, and 76% reported that residents’ personal lives improved.

Table Graphic Jump LocationTable 5. Summary of Study Designs, Interventions, and Outcomes of Family Medicine, Psychiatry, and Radiology Programs

In a survey study of psychiatry residents on the impact of night float, there was a mean rating of improvement in their well-being (on a 1-5 scale with 1 = strongly agree: 2.10), education (1.71), and clinical duties (1.86).74

Two studies assessed radiology residents. In a multi-institutional survey of chief residents, 85% reported improved call experience and 90% reported better educational experience after the ACGME work hour rules were put into effect.75 The number of in-hospital call sessions increased from 104 in 2000 to 114 in 2004, while the number of home calls increased from 57 to 63.

In the second study, in a single program that instituted a night float system, 45% of residents reported that their clinical judgment was better during the night float than on a 24-hour long call shift; the others did not think that their judgment was affected by night float.76 However, residents also reported that it took them about 2 days to acclimate to beginning night float and about 2 days to return to a normal schedule afterward.

Review of Abstracts

Summaries of the relevant abstracts from the national Society of General Internal Medicine meetings and the Research in Medical Education of the Association of American Medical Colleges are shown in eTable 5.7791 Their findings corroborate those of the published studies.

Limiting resident work hours may impact faculty members, nurses, medical students, and patients, as well as the residents themselves.16 Just as the safety of patients may not always be improved by interventions intended to decrease resident work hours,17 our review indicates that there may not be uniform benefits for residents from these changes.

Policy changes such as these have both intended and unintended consequences. The ACGME Statement of Justification for the work hour limits states that the intended consequences for residents include improvements in their education and well-being.92 However, potential unintended consequences include inadequate development of professionalism93 and worse patient-physician communication skills,94 and these have not been explored.

Home call was part of 4 programs’ interventions to decrease work hours. No specific assessment of the impact on the residents taking home call was performed, and these are hours that are not counted toward the 80-hour per week limit. The impact of home call on sleep and personal life may be substantial. Some of the studies that assessed the experience of residents assigned to night float found some disadvantages. Residents reported more difficulty sleeping41 and mixed feelings about the educational value of the night float rotation.33 The effect of home call and night float should be accurately assessed in programs that use them.

Another potential unintended consequence of reducing resident hours is a decrease in experience, and some educators argue that reduced hours for residents may necessitate more years of training.95 Actual experience was studied in surgery and obstetrics/gynecology programs, but not in the other specialties. Some of these studies demonstrated reduced experience,35,57 while some demonstrated increased operative experience.48 The findings of these studies raise the possibility that some interventions intended to decrease work hours may have varying impact at different levels of training. A benefit of reduced fatigue may be worthwhile if operative experience evens out over the course of training. However, it may be problematic if residents have decreased experience in their final year before leaving training, as was found in one study.35

Resident experience could be thought of as a process-of-care measurement because its real importance is in how it affects patient care.96 Research in this area should focus on the link between resident experience and patient outcomes. For example, tracking outcomes of recent graduates in their first 5 years after training, such as surgical morbidity and mortality, using specific operative experience during residency as a predictor, would identify the amount of experience needed during residency to achieve clinical competence.

The debate on resident work hours focuses on the balance between protecting residents and caring for patients. In several studies, we found that residents thought that fatigue had less impact on care after their work hours were decreased. As suggested by the link between resident burnout and self-perceived quality of care,97 improved quality of life for residents may ultimately result in better patient care, but this will need to be empirically established.

Quiz Ref IDThis systematic review should be interpreted within the context of several limitations. First, the experience of many individual institutions is likely unpublished. Publication bias could influence the results of our review, especially if the unpublished studies were more likely to have shown no significant effect of an intervention.98 However, unpublished abstracts showed results similar to the published studies. Second, the methodology of the included studies differed and was often suboptimal. Only 1 study used a randomized controlled design,26 and most of the other studies did not measure or adjust for possible confounders. Many of the studies relied exclusively on surveys, and some were done at a single time point, asking the residents to reflect on their experiences before and after interventions. Asking participants to remember events in the past can lead to problems with validity, especially when events occurred remotely or when respondents must recall many events.99 Third, the interventions evaluated were divergent, making it challenging to draw firm conclusions about the relative merits and drawbacks of individual systems for reducing resident work hours.

These limitations suggest steps to improve the quality of research in this area. First, programs instituting substantial changes should rigorously study these changes and report them, whether or not they demonstrate an impact. Second, interventions should be studied at multiple institutions to improve the generalizability of the findings. Third, whenever possible, intervention studies should be conducted as randomized controlled trials to reduce the effect of confounding. Survey studies can provide valuable insight into the impact of an intervention, but they must also be performed rigorously. Investigators should use standardized methods for developing and validating the survey, maximizing the response rate, and properly reporting response rate and results.21,99

Objective outcomes rather than perceived outcomes should be measured. Several studies in this review surveyed residents about perceived amount of sleep, even though more reliable methods are available and were used in other studies; these approaches may produce different results.41,42 While actual clinical experience was measured in some studies of surgery and obstetrics/gynecology residents, we found no studies that measured actual experience in internal medicine, pediatrics, family medicine, or psychiatry. An important outcome to consider is not only the number of patients with a given condition (eg, acute myocardial infarction) that are cared for by a resident during his or her training, but also the number of such patients followed up from admission to discharge. This continuity experience is particularly vulnerable to use of a night float system.

A valid, reliable survey tool for measuring resident quality of life needs to be developed if there is to be accurate measurement of the impact of programmatic and policy-level changes on residents. It is also necessary to study the link between resident quality of life, burnout, and patient care.100

Despite these limitations, this study provides a comprehensive review of the literature and our current understanding of the effects that attempts at work hour limitations have had on the quality of life and educational experiences of residents. It suggests that residents’ quality of life may improve with the ACGME limitations on resident work hours. The short-term effects of interventions to decrease resident work hours on education are mixed, however, and longer-term studies will be needed to understand the impact of the changes on resident experience, knowledge acquisition, and the link between these and patient outcomes. We have outlined several areas of research that could make important contributions to our understanding of how best to nurture residents while also providing excellent patient care both during training and when these residents become practicing physicians.

Corresponding Author: Kathlyn E. Fletcher, MD, MA, Primary Care Division, Clement J. Zablocki VAMC, 5000 W National Ave, Milwaukee, WI 53295 (kathlyn.fletcher@med.va.gov).

Author Contributions: Dr Fletcher had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Fletcher, Underwood, Davis.

Acquisition of data: Fletcher, Underwood, Davis.

Analysis and interpretation of data: Fletcher, Davis, Mangrulkar, McMahon, Saint.

Drafting of the manuscript: Fletcher, Davis, McMahon.

Critical revision of the manuscript for important intellectual content: Underwood, Davis, Mangrulkar, McMahon, Saint.

Statistical analysis: Fletcher, Davis.

Obtained funding: Saint.

Administrative, technical, or material support: Davis, McMahon.

Study supervision: Mangrulkar, McMahon.

Financial Disclosures: None reported.

Funding/Support: The University of Michigan’s Patient Safety Enhancement Program supported this project. Dr Saint is supported by a Career Development Award from the Health Services Research & Development Program of the Department of Veterans Affairs and a Patient Safety Developmental Center grant from the Agency for Healthcare Research and Quality (P20-HS11540). Dr Fletcher was a Robert Wood Johnson Clinical Scholar/Veterans Affairs Scholar when some of this work was completed.

Role of the Sponsors: The sponsors had no role in the design or conduct of the study; no involvement in the management, analysis, and interpretation of the data; and did not review or approve the manuscript.

Previous Presentations: Part of this work was presented at the national Society of General Internal Medicine meeting in May 2003 in Vancouver, British Columbia, and part at the Society of Hospital Medicine meeting in April 2005 in Chicago, Ill.

Additional Information: The tables in print are abridged. The complete detailed tables are available here.

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Harris RP, Helfand M, Woolf SH.  et al. Methods Work Group, Third US Preventive Services Task Force.  Current methods of the US Preventive Services Task Force: a review of the process.  Am J Prev Med. 2001;20:(3 suppl)  21-35
PubMed   |  Link to Article
Fink A, Kosecoff JB. How to Conduct Surveys: A Step-by-Step GuideThousand Oaks, Calif: Sage Publications; 1998
 Standards and best practices. American Association for Public Opinion Research Web site. Available at: http://www.aapor.org/default.asp?page=survey_methods/standards_and_best_practices/best_practices_for_survey_and_public_opinion_research. 2002. Accessed May 31, 2005
Fowler FJ. Survey Research Methods3rd ed. Thousand Oaks, Calif: Sage Publications; 2002. Applied Social Science Research Methods Series
Buff DD, Shabti R. The night float system of resident on call: what do the nurses think?  J Gen Intern Med. 1995;10:400-402
PubMed   |  Link to Article
Conigliaro J, Frishman WH, Lazar EJ, Croen L. Internal medicine housestaff and attending physician perceptions of the impact of the New York State Section 405 regulations on working conditions and supervision of residents in two training programs.  J Gen Intern Med. 1993;8:502-507
PubMed   |  Link to Article
Gottlieb DJ, Parenti CM, Peterson CA, Lofgren RP. Effect of a change in house staff work schedule on resource utilization and patient care.  Arch Intern Med. 1991;151:2065-2070
PubMed   |  Link to Article
Gottlieb DJ, Peterson CA, Parenti CM, Lofgren RP. Effects of a night float system on housestaff neuropsychologic function.  J Gen Intern Med. 1993;8:146-148
PubMed   |  Link to Article
Lockley SW, Cronin JW, Evans EE.  et al.  Effect of reducing interns’ weekly work hours on sleep and attentional failures.  N Engl J Med. 2004;351:1829-1837
PubMed   |  Link to Article
Richardson GS, Wyatt JK, Sullivan JP.  et al.  Objective assessment of sleep and alertness in medical house staff and the impact of protected time for sleep.  Sleep. 1996;19:718-726
PubMed
Rosenberg M, McNulty D. Beyond night float? the impact of call structure on internal medicine residents.  J Gen Intern Med. 1995;10:95-98
PubMed   |  Link to Article
Seelig CB. Changes in residents' attitudes in response to residency program modifications: a prospective study.  South Med J. 1992;85:972-975
PubMed   |  Link to Article
Seelig CB. Quantitating qualitative issues in residency training: development and testing of a scaled program evaluation questionnaire.  J Gen Intern Med. 1993;8:610-613
PubMed   |  Link to Article
Trontell MC, Carson JL, Taragin MI, Duff A. The impact of the night float system on internal medicine residency programs.  J Gen Intern Med. 1991;6:445-449
PubMed   |  Link to Article
Wong JG, Holmboe ES, Huot SJ. Teaching and learning in an 80-hour work week: a novel day-float rotation for medical residents.  J Gen Intern Med. 2004;19:519-523
PubMed   |  Link to Article
Yedidia MJ, Lipkin M Jr, Schwartz MD, Hirschkorn C. Doctors as workers: work-hour regulations and interns' perceptions of responsibility, quality of care, and training.  J Gen Intern Med. 1993;8:429-435
PubMed   |  Link to Article
 Section 405.4-Medical staff. Available at: http://w3.health.state.ny.us/dbspace/NYCRR10.nsf. Accessed April 26, 2004
Blanchard MH, Amini SB, Frank TM. Impact of work hour restrictions on resident case experience in an obstetrics and gynecology residency program.  Am J Obstet Gynecol. 2004;191:1746-1751
PubMed   |  Link to Article
Carey JC, Fishburne JI. A method to limit working hours and reduce sleep deprivation in an obstetrics and gynecology residency program.  Obstet Gynecol. 1989;74:668-672
PubMed
Cohen BL. The impact and practical aspects of the implementation of the new working conditions for residents in the Department of Obstetrics and Gynecology at the Albert Einstein College of Medicine.  Bull N Y Acad Med. 1991;67:338-343
PubMed
Kelly A, Marks F, Westhoff C, Rosen M. The effect of the New York State restrictions on resident work hours.  Obstet Gynecol. 1991;78:468-473
PubMed
Nichols M. Curriculum change in an obstetrics-gynecology residency program and its impact on pregnancy in residency.  Am J Obstet Gynecol. 1994;170:1658-1664
PubMed
Seltzer V, Foster HW Jr, Gordon M. Resident scheduling: night float programs.  Obstet Gynecol. 1991;77:940-943
PubMed
Cavallo A, Jaskiewicz J, Ris MD. Impact of night-float rotation on sleep, mood, and alertness: the resident's perception.  Chronobiol Int. 2002;19:893-902
PubMed   |  Link to Article
Cavallo A, Ris MD, Succop P. The night float paradigm to decrease sleep deprivation: good solution or a new problem?  Ergonomics. 2003;46:653-663
PubMed   |  Link to Article
Daigler GE, Welliver RC, Stapleton FB. New York regulation of residents' working conditions: 1 year's experience.  AJDC. 1990;144:799-802
PubMed
Kuo AK, Ma CT, Kamei RK. Evening continuity clinic: preserving primary care education in the face of duty hour limitations?  Ambul Pediatr. 2004;4:332-335
PubMed   |  Link to Article
Lieu TA, Forrest CB, Blum NJ, Cornfeld D, Polin RA. Effects of a night-float system on resident activities and parent satisfaction [correction appears in.AJDC 1992;146:664]  AJDC. 1992;146:307-310
PubMed
Ozuah PO, Neuspiel DR, Shelov SP. The pediatric forum: trends in residents' perceptions of working conditions: 1989-1999.  Arch Pediatr Adolesc Med. 2001;155:1073-1074
PubMed
Samuels RC, Chi GW, Rauch DA, Palfrey JS, Shelov S. Lessons from pediatrics residency program directors' experiences with work hour limitations in New York state.  Acad Med. 2005;80:467-472
PubMed   |  Link to Article
Barden CB, Specht MC, McCarter MD, Daly JM, Fahey TJ III. Effects of limited work hours on surgical training.  J Am Coll Surg. 2002;195:531-538
PubMed   |  Link to Article
Basu CB, Chen LM, Hollier LH Jr, Shenaq SM. The effect of the Accreditation Council for Graduate Medical Education duty hours policy on plastic surgery resident education and patient care: an outcomes study.  Plast Reconstr Surg. 2004;114:1878-1887
PubMed   |  Link to Article
Chandra RK. The resident 80-hour work week: how has it affected surgical specialties?  Laryngoscope. 2004;114:1394-1398
PubMed   |  Link to Article
Chung R, Ahmed N, Chen P. Meeting the 80-hour work week requirement: what did we cut?  Curr Surg. 2004;61:609-611
PubMed   |  Link to Article
Cockerham WT, Cofer JB, Lewis PL, Scroggins CM, Burns RP. Resident work hours: can we meet the ACGME requirements?  Am Surg. 2004;70:687-690
PubMed
Cohen-Gadol AA, Piepgras DG, Krishnamurthy S, Fessler RD. Resident duty hours reform: results of a national survey of the program directors and residents in neurosurgery training programs.  Neurosurgery. 2005;56:398-402
PubMed   |  Link to Article
Curet MJ, McAdams TR. Improving resident work environment: evaluation of a novel cooperative program.  Surgery. 2003;134:158-163
PubMed   |  Link to Article
Fassler S, Dobkin ED, Horowitz S, Morejon O, Reilly P, Civetta J. Lemonade from lemons: a program response to RRC-determined probation.  Curr Surg. 2000;57:373-376
PubMed   |  Link to Article
Gelfand DV, Podnos YD, Carmichael JC, Saltzman DJ, Wilson SE, Williams RA. Effect of the 80-hour workweek on resident burnout.  Arch Surg. 2004;139:933-938
PubMed   |  Link to Article
Goldstein MJ, Kim E, Widmann WD, Hardy MA. A 360 degrees evaluation of a night-float system for general surgery: a response to mandated work-hours reduction.  Curr Surg. 2004;61:445-451
PubMed   |  Link to Article
Goldstein MJ, Samstein B, Ude A, Widmann WD, Hardy MA. Work Hours Assessment and Monitoring Initiative (WHAMI) under resident direction: a strategy for working within limitations.  Curr Surg. 2005;62:132-137
PubMed   |  Link to Article
Hassett JM, Nawotniak R, Cummiskey D.  et al.  Maintaining outcomes in a surgical residency while complying with resident working hour regulations.  Surgery. 2002;132:635-639
PubMed   |  Link to Article
Jarman BT, Miller MR, Brown RS.  et al.  The 80-hour work week: will we have less-experienced graduating surgeons?  Curr Surg. 2004;61:612-615
PubMed   |  Link to Article
Price Kerfoot B, Nabha KS, Hafler JP. The impact of duty hour restrictions on teaching by surgical residents.  Med Educ. 2005;39:528-529
Link to Article
Kort KC, Pavone LA, Jensen E, Haque E, Newman N, Kittur D. Resident perceptions of the impact of work-hour restrictions on health care delivery and surgical education: time for transformational change.  Surgery. 2004;136:861-871
PubMed   |  Link to Article
Mendoza KA, Britt LD. Resident operative experience during the transition to work-hour reform.  Arch Surg. 2005;140:137-145
PubMed   |  Link to Article
Nemes J, Barnaby K, Shamberger RC. Experience with a nurse practitioner program in the surgical department of a children's hospital.  J Pediatr Surg. 1992;27:1038-1040
PubMed   |  Link to Article
Podnos YD, Williams RA, Jimenez JC, Stemmer EA, Gordon IL, Wilson SE. Reducing the noneducational and nonclinical workload of the surgical resident: defining the role of the health technician.  Curr Surg. 2003;60:529-532
PubMed   |  Link to Article
Spencer AU, Teitelbaum DH. Impact of work-hour restrictions on residents' operative volume on a subspecialty surgical service.  J Am Coll Surg. 2005;200:670-676
PubMed   |  Link to Article
Spisso J, O'Callaghan C, McKennan M, Holcroft JW. Improved quality of care and reduction of housestaff workload using trauma nurse practitioners.  J Trauma. 1990;30:660-663
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Stamp T, Termuhlen PM, Miller S.  et al.  Before and after resident work hour limitations: an objective assessment of the well-being of surgical residents.  Curr Surg. 2005;62:117-121
PubMed   |  Link to Article
Victorino GP, Organ CH Jr. Physician assistant influence on surgery residents.  Arch Surg. 2003;138:971-975
PubMed   |  Link to Article
Welling RE, Boberg JT, Weinberg E, Gulley J. Work hours compliance in a community hospital.  Curr Surg. 2004;61:241-243
PubMed   |  Link to Article
Whang EE, Mello MM, Ashley SW, Zinner MJ. Implementing resident work hour limitations: lessons from the New York State experience.  Ann Surg. 2003;237:449-455
PubMed
Winslow ER, Berger L, Klingensmith ME. Has the 80-hour work week increased faculty hours?  Curr Surg. 2004;61:602-608
PubMed   |  Link to Article
Yu JN. Night shift call systems in family practice residencies.  Fam Med. 1994;26:163-167
PubMed
Druss BG, Pelton G, Lyons L, Sledge WH. Resident and faculty evaluations of a psychiatry night-float system.  Acad Psychiatry. 1996;20:26-34
Peterson CM, Gerstle R, Bhalla S, Menias CO, Jost RG. Results of the 2004 survey of the American Association of Academic Chief Residents in Radiology.  Acad Radiol. 2005;12:373-378
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Reader DW, Spigos DG, Bennett WF, Mueller CF, Vaswani KK. The graveyard shift: experience with a night float system.  Emerg Radiol. 2002;9:82-87
PubMed
Lieberman J, Olenwine MS, Nicholas G. Residency reform: initial effects of ACGME guidelines on a surgical residency program [abstract].  Res Med Educ2004; 4
Akl EA, Bais A, Rich E, Izzo J, Grant BJ, Schunemann HJ. Comparison of internal medicine residents, attendings and nurses perceptions of the night float system.  J Gen Intern Med. 2005;20:(suppl 1)  150
Arora V, Dunphy C, Chang V, Ahmad F, Humphrey HJ, Meltzer DO. A randomized controlled trial of night float: effects on resident sleep, fatigue, and patient care [abstract].  J Gen Intern Med. 2005;20:(suppl 1)  146
Hillson S, Wilson J, Rich EC, Lyttle CS. Program directors’ opinions regarding stress [abstract].  J Gen Intern Med. 1995;10:(suppl 1)  89
PubMed   |  Link to Article
Hunter A, Harrison RA, Desai S, Dickey J, Choi D, Girard D. Developing methodology to monitor the ACGME duty hour requirements: a graduate medical education tool [abstract].  J Gen Intern Med. 2005;20:(suppl 1)  182
Jasti H, Hanusa BH, Switzer G, Granieri R, Elnicki M. Residents' perceptions and attitudes towards a night float system.  J Gen Intern Med. 2004;19:(suppl 1)  205
PubMed   |  Link to Article
Jasti H, Hanusa BH, Granieri R, Elnicki M. Addressing residents' attitudes towards a night float system using a multi-dimensional scaled questionnaire [abstract].  J Gen Intern Med. 2004;19:(suppl 1)  121
Kaushal H, Fischer J, Khurana H, Reddy A. Does night float impact the quality of the admit history and physical?  J Gen Intern Med. 2004;19:(suppl 1)  145
Kripalani S, Williams MV. Impact of a night float system on housestaff satisfaction [abstract].  J Gen Intern Med. 2001;16:(suppl 1)  102
Mathis BR, Diers T, Rouan GW. Varying opinion between residents and faculty on the impact of modifying a general internal medicine ward service to meet ACGME guidelines [abstract].  J Gen Intern Med. 2004;19:(suppl 1)  235
Mercado JM, Tulsky A. Night float-an intern's experience [abstract].  J Gen Intern Med. 2004;19:(suppl 1)  182
Olshausen P, Ijo-Su E, Charney P. Exploring internal medicine night float (INF) responsibilities [abstract].  J Gen Intern Med. 2005;20:(suppl 1)  155
PubMed   |  Link to Article
Parekh VI, Sharpe B, Fletcher KE, Cornia P, Vidyarthi A. The impact of resident work hours limits on internal medicine residents' continuity clinic experience [abstract].  J Gen Intern Med. 2005;20:(suppl 1)  165
Link to Article
Talente GM, Staton LJ, Carroll MR, Mumtaz M, Larsen LC. ACGME duty hour requirements, what do faculty think? [abstract].  J Gen Intern Med. 2005;20:(suppl 1)  147
Vidyarthi AR, Katz P, Wachter RM, Auerbach AD. Impact of reduced duty hours on educational satisfaction of internal medicine housestaff [abstract].  J Gen Intern Med. 2004;19:(suppl 1)  164
 Statement of Justification/Impact for the Final Approval of Common Standards Related to Resident Duty HoursChicago, Ill: ACGME; 2003. Available at: http://www.acgme.org/DutyHours/impactStatement.pdf. Accessed February 21, 2003
Rosenbaum JR. Can residents be professional in 80 or fewer hours a week?  Am J Med. 2004;117:846-850
PubMed   |  Link to Article
Stern DT, Saint S, Tierney LM Jr. Where have all the hours gone?  South Med J. 2001;94:651-654
PubMed   |  Link to Article
Saultz JW, David AK. Is it time for a 4-year family medicine residency?  Fam Med. 2004;36:363-366
PubMed
Donabedian A. Volume 1: The Definition of Quality and Approaches to Its Assessment . Ann Arbor, Mich: Health Administration Press; 1980. Explorations in quality assessment and monitoring.
Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program.  Ann Intern Med. 2002;136:358-367
PubMed   |  Link to Article
Dickersin K. The existence of publication bias and risk factors for its occurrence.  JAMA. 1990;263:1385-1389
PubMed   |  Link to Article
Converse JM, Presser S. Survey Questions: Handcrafting the Standardized Questionnaire . Beverly Hills, Calif: Sage Publications; 1986. Sage University Paper series on Quantitative Applications in the Social Sciences, series no. 07-063
Thomas NK. Resident burnout.  JAMA. 2004;292:2880-2889
PubMed   |  Link to Article

Tables

Table Graphic Jump LocationTable 1. Summary of Study Designs, Interventions, and Outcomes of Internal Medicine Programs
Table Graphic Jump LocationTable 2. Summary of Study Designs, Interventions, and Outcomes of Obstetrics/Gynecology Programs
Table Graphic Jump LocationTable 3. Summary of Study Designs, Interventions, and Outcomes of Pediatrics Programs
Table Graphic Jump LocationTable 4. Summary of Study Designs, Interventions, and Outcomes of Surgery Programs
Table Graphic Jump LocationTable 5. Summary of Study Designs, Interventions, and Outcomes of Family Medicine, Psychiatry, and Radiology Programs

References

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PubMed   |  Link to Article
Fletcher KE, Davis SQ, Underwood W, Mangrulkar R, McMahon LF, Saint S. Systematic review: effects of resident work hours on patient safety.  Ann Intern Med. 2004;141:851-857
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Harris RP, Helfand M, Woolf SH.  et al. Methods Work Group, Third US Preventive Services Task Force.  Current methods of the US Preventive Services Task Force: a review of the process.  Am J Prev Med. 2001;20:(3 suppl)  21-35
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Fink A, Kosecoff JB. How to Conduct Surveys: A Step-by-Step GuideThousand Oaks, Calif: Sage Publications; 1998
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Fowler FJ. Survey Research Methods3rd ed. Thousand Oaks, Calif: Sage Publications; 2002. Applied Social Science Research Methods Series
Buff DD, Shabti R. The night float system of resident on call: what do the nurses think?  J Gen Intern Med. 1995;10:400-402
PubMed   |  Link to Article
Conigliaro J, Frishman WH, Lazar EJ, Croen L. Internal medicine housestaff and attending physician perceptions of the impact of the New York State Section 405 regulations on working conditions and supervision of residents in two training programs.  J Gen Intern Med. 1993;8:502-507
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Gottlieb DJ, Parenti CM, Peterson CA, Lofgren RP. Effect of a change in house staff work schedule on resource utilization and patient care.  Arch Intern Med. 1991;151:2065-2070
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Gottlieb DJ, Peterson CA, Parenti CM, Lofgren RP. Effects of a night float system on housestaff neuropsychologic function.  J Gen Intern Med. 1993;8:146-148
PubMed   |  Link to Article
Lockley SW, Cronin JW, Evans EE.  et al.  Effect of reducing interns’ weekly work hours on sleep and attentional failures.  N Engl J Med. 2004;351:1829-1837
PubMed   |  Link to Article
Richardson GS, Wyatt JK, Sullivan JP.  et al.  Objective assessment of sleep and alertness in medical house staff and the impact of protected time for sleep.  Sleep. 1996;19:718-726
PubMed
Rosenberg M, McNulty D. Beyond night float? the impact of call structure on internal medicine residents.  J Gen Intern Med. 1995;10:95-98
PubMed   |  Link to Article
Seelig CB. Changes in residents' attitudes in response to residency program modifications: a prospective study.  South Med J. 1992;85:972-975
PubMed   |  Link to Article
Seelig CB. Quantitating qualitative issues in residency training: development and testing of a scaled program evaluation questionnaire.  J Gen Intern Med. 1993;8:610-613
PubMed   |  Link to Article
Trontell MC, Carson JL, Taragin MI, Duff A. The impact of the night float system on internal medicine residency programs.  J Gen Intern Med. 1991;6:445-449
PubMed   |  Link to Article
Wong JG, Holmboe ES, Huot SJ. Teaching and learning in an 80-hour work week: a novel day-float rotation for medical residents.  J Gen Intern Med. 2004;19:519-523
PubMed   |  Link to Article
Yedidia MJ, Lipkin M Jr, Schwartz MD, Hirschkorn C. Doctors as workers: work-hour regulations and interns' perceptions of responsibility, quality of care, and training.  J Gen Intern Med. 1993;8:429-435
PubMed   |  Link to Article
 Section 405.4-Medical staff. Available at: http://w3.health.state.ny.us/dbspace/NYCRR10.nsf. Accessed April 26, 2004
Blanchard MH, Amini SB, Frank TM. Impact of work hour restrictions on resident case experience in an obstetrics and gynecology residency program.  Am J Obstet Gynecol. 2004;191:1746-1751
PubMed   |  Link to Article
Carey JC, Fishburne JI. A method to limit working hours and reduce sleep deprivation in an obstetrics and gynecology residency program.  Obstet Gynecol. 1989;74:668-672
PubMed
Cohen BL. The impact and practical aspects of the implementation of the new working conditions for residents in the Department of Obstetrics and Gynecology at the Albert Einstein College of Medicine.  Bull N Y Acad Med. 1991;67:338-343
PubMed
Kelly A, Marks F, Westhoff C, Rosen M. The effect of the New York State restrictions on resident work hours.  Obstet Gynecol. 1991;78:468-473
PubMed
Nichols M. Curriculum change in an obstetrics-gynecology residency program and its impact on pregnancy in residency.  Am J Obstet Gynecol. 1994;170:1658-1664
PubMed
Seltzer V, Foster HW Jr, Gordon M. Resident scheduling: night float programs.  Obstet Gynecol. 1991;77:940-943
PubMed
Cavallo A, Jaskiewicz J, Ris MD. Impact of night-float rotation on sleep, mood, and alertness: the resident's perception.  Chronobiol Int. 2002;19:893-902
PubMed   |  Link to Article
Cavallo A, Ris MD, Succop P. The night float paradigm to decrease sleep deprivation: good solution or a new problem?  Ergonomics. 2003;46:653-663
PubMed   |  Link to Article
Daigler GE, Welliver RC, Stapleton FB. New York regulation of residents' working conditions: 1 year's experience.  AJDC. 1990;144:799-802
PubMed
Kuo AK, Ma CT, Kamei RK. Evening continuity clinic: preserving primary care education in the face of duty hour limitations?  Ambul Pediatr. 2004;4:332-335
PubMed   |  Link to Article
Lieu TA, Forrest CB, Blum NJ, Cornfeld D, Polin RA. Effects of a night-float system on resident activities and parent satisfaction [correction appears in.AJDC 1992;146:664]  AJDC. 1992;146:307-310
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