Longer hours show no significant impact on resident satisfaction or patient care

Surgical residents who are allowed to work longer hours than currently allowed so that they can stay with or stabilize patients do not show any signs of putting their patients at risk, according to a recent study published by the New England Journal of Medicine.

Karl Y. Bilimoria, MD, MSCI, Surgical Outcomes and Quality Improvement Center at Northwestern University’s Feinberg School of Medicine, and colleagues completed the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial to compare resident workload policies drafted by the Accreditation Council for Graduate Medical Education (ACGME) with “flexible, less restrictive” alternatives.

The ACGME last updated its resident duty policies in 2011, limiting residents to 80-hour work weeks, requiring one day off out of every seven days, capping shifts at 16 or 24 consecutive hours (depending on the residency year), and putting several other specific requirements into place

Bilimoria and colleagues studied 118 general surgery residency programs and 154 affiliated hospitals from July 1, 2014, to June 30, 2015. (Programs from New York state were excluded due to specific resident regulations that are already in place.)

The programs were then separated into two groups: a “standard-policy” group and a “flexible-policy” group. Residents in the standard-policy group performed their duties as usual, and those in the flexible-policy group were granted a waiver to ignore certain ACGME policies so that they could provide continuous care to patients and stabilize patients as needed.

Overall, the authors found no significant changes in the care provided by residents in flexible-policy programs. The rate of death or serious complications, for example, was 9 percent in the standard-policy group and 9.1 percent in the flexible-policy group.

“Our finding of noninferior patient outcomes under flexible, less-restrictive duty-hour policies as compared with standard duty-hour policies for most postoperative outcomes examined is consistent with the results of previous studies,” the authors wrote. “Moreover, there were no significant differences between the standard-policy and flexible-policy groups in outcomes for subgroups that may be more sensitive to differences in duty-hour policies, including high-risk patients, inpatient surgeries, and emergency cases. Thus, these findings suggest that flexible duty-hour policies appear to be safe for patient care.”

Also, residents were dissatisfied with their overall education policy 10.7 percent of the time in the standard-policy group and 11 percent of the time in the flexible-policy group.

In addition, Bilimoria et al. noted that the flexible-policy group was technically working longer hours, but the residents did not seem to necessarily mind.

“These results suggest that residents found that flexible duty-hour policies improved multiple aspects of patient care and resident education without an appreciable difference in their personal safety, but these benefits came with the recognition that the flexible policies affected time for personal activities and certain aspects of well-being,” the authors wrote.

The team behind the FIRST Trial did note some limitations. For example, they were limited to resident programs affiliated with hospitals that used ACS National Surgical Quality Improvement Program (ACS NSQIP) for patient data collection, so the study may not accurately represent programs that are not affiliated with ACS NSQIP hospitals.

Another limitation of the study, Bilimoria and colleagues explained, is that it only tracked residents for one year of their training.

“We conducted this study for a full academic year, but we cannot extrapolate the ways in which flexible duty-hour policies might affect the training and experience of an entire cohort of surgical residents over multiple years,” the authors wrote.