Changes in Shift Work Policy: From Residency to Practice

Residency is an essential milestone among the multiple stages of a medical education. After attending medical school, participating in required clinical rotations and sub-internships, and completing a post-graduation internship year, qualified medical students go on to become junior residents. The residency experience is comprised of clinical education as well as job experience. It functions not only to prepare residents for their ultimate specialty, but also to help them acclimate to the rigors of the profession. Every aspiring anesthesiologist in the U.S. will attend a three-year residency program after an internship year that includes clinical experience in the operating room (OR), as well as educational programs such as grand rounds and conferences.[1] After successfully completing their residency programs and obtaining the proper state-specific certifications and licenses, many aspiring anesthesiologists will complete a fellowship year. Sub-specialty fellowships allow residents to become experts in a specific field within anesthesiology, such as critical care medicine or pediatric anesthesia. Each stage of residency training serves as a trial period of sorts for the lifestyle of an anesthesiologist, which often requires long shifts, 24-hour calls, unpredictable hours, and any additional stressors associated with the surgical profession. In recent years, shift work policies have emerged as a topic of discussion in anesthesiology, as well as in the broader conversation in health policy research. From residency to practice, there is a newfound focus on shift work as a possible area for reform.

Since the advent of formal training programs for physicians, medical educators in anesthesiology, as well as many other disciplines, have insisted that residents work long hours to adequately prepare themselves for the life of a practicing physician. The length of the average residency shift in the United States has decreased incrementally over time. Before the 1980s, it was not uncommon for residents to work 90-100 hour weeks, with shifts that lasted up to 36 hours.[2] The Bell Commission was established in response to cases of tragic patient outcomes that could have been attributed to resident physician sleep deprivation. The Commission sought to limit resident shifts to 80 hours per week in a four-week period, to restrict individual shifts to 24 consecutive hours, and to implement mandatory off-shifts.[3] The Bell Commission was adopted by prominent hospitals in the New York area before it was taken up by other states in the U.S. Despite these changes, the debate continued over the benefits of instituting 16-hour vs. 24-hour individual shift limits.


In an attempt to shed some light on the matter, a research team led by sleep expert and Harvard physician Dr. Charles Czeisler studied the effect of reducing residency shift times to 16-hours on intern and resident quality of sleep and attentional failures.[4] Sleep times were monitored for interns and residents participating in the study, taking into account sleep interruptions due to clinical responsibility requests. The research team found a direct correlation between increased shift hours and frequency of attentional failures. These results provided the impetus to focus policy discussions and initiatives around shift regulations. The call for shorter shift times was furthered by evidence generated from a recent study, which showed a significant relationship between reduced shift time and resident reporting on quality of life and training outcomes.[5] Most notably, the study found no significant difference in board examination results between the experimental and standard cohort. This finding suggests that the clinical education obtained by shift-limited residents is comparable to that of residents working standard, non-limited hours. Future research will aim to uncover innovative methods of shift design that continue to improve life satisfaction and occupational efficacy for residents, while also optimizing educational training, clinical training, and certification exam scores.

Following residency and a possible fellowship, trained anesthesiologists establish themselves in a diverse array of clinical settings: from academic medicine, to outpatient surgical facilities, to private practice. In any setting, it is evident that policies around shift work and resident training will continue to evolve. As leaders in healthcare, anesthesiologists can welcome and encourage the new wave of resident education.


[1] The American Board of Anesthesiology. Training/Residents. 2016.

[2] Patient Safety Primer. Duty Hours and Patient Safety. Aug 2018. The Agency for Healthcare Research and Quality.

[3] Wallack MK, Chao L. Resident Work Hours: The Evolution of a Revolution. Arch Surg. 2001;136(12):1426–1432. doi:10.1001/archsurg.136.12.1426

[4] Lockley SW et al. “Effect of reducing interns’ weekly work hours on sleep and attentional failures.” N Engl J Med. 2004 Oct 28;351(18):1829-37.

[5] Hedin M. Johns Hopkins University HUB. “Study: Limiting shifts for medical trainees improves satisfaction without affecting educational outcomes.” Mar 2018.

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