U.S. Department of Defense


Date of this Version



Published in The American Journal of Medicine (2011) 124(7): 671-676; doi:10.1016/j.amjmed.2011.03.019


In 2003, the Accreditation Council for Graduate Medical Education defined for the first time an upper limit on the number of hours that residents can work. This initial reduction in work hours was made with the goal of improving patient safety, resident education, and resident well-being. Now, 8 years later, further duty hour restrictions are slated to take effect July 1, 2011. These new reductions are largely a response to growing public concern about the effects of sleep deprivation on residents. Educators and residents alike have mixed opinions about the effects of prior and future duty hour restrictions on resident education.3 The potential effects of resident duty hour restrictions on medical student education have received less attention.

Changes to graduate medical education have the potential to affect medical students’ experiences and learning during their clerkships. With further duty hour restrictions imminent, now is the ideal time to learn from past duty hour restrictions and predict the likely effects of further resident duty hour restrictions on medical students. A forward-looking approach to the new duty hours regulations allows medical educators to anticipate, and potentially prevent, negative effects while providing an opportunity to capitalize on potential benefits.

This article provides an overview of the current knowledge of the effects of duty hour restrictions on medical student education to guide educators in planning for consequences of further resident duty hour restrictions. A literature review was conducted using the MeSH subheadings “internship and residency” and “students, medical.” These reviews were then combined with separate key word searches using the terms “duty hours” and “work hours.” For articles deemed relevant to this topic, a related article search was conducted in PubMed and included articles’ references were reviewed for relevance. The authors of this article include clerkship directors and medical educators, and many have published previously on this topic. This article was reviewed and endorsed by the Clerkship Directors in Internal Medicine Council in January 2011.

A narrative review of the literature demonstrates that most of the concerns regarding resident duty hour restrictions and medical student education address 4 key areas. These areas include teaching, discontinuity, team structure, and educational climate. Teaching concerns relate to residents’ role as educator and rounds and the role of the attending. Discontinuity concerns relate to shift work and handoffs. For each area, we have summarized the current literature and interpreted the effects of these changes on medical student education. We also include best practices for teaching students in the context of these changes.