Patient care and safety are priorities for surgery residents who work flexible schedules

U.S. general surgery residents are selectively making the choice to work additional hours when needed to manage critical stages in patient care, according to results from a national survey conducted as part of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial. The trial, the first-ever national multicenter randomized study of resident duty (work) hour policies, began with the 2015-2016 academic year.

While initial results of the trial published earlier this year¹ showed no difference in patient outcomes and perceptions by residents of their overall well-being and quality of education, residents did perceive that aspects of patient care and training were improved with more flexible work hours. Two new studies on residents' perceptions explore when and why residents choose to prolong their work shifts. These studies appear online as an "article in press" on the Journal of the American College of Surgeons website in advance of print publication.

A total of 3,795 residents from 117 residency training programs in the FIRST Trial completed the survey in January 2016 (response rate 95 percent) as part of the American Board of Surgery In-Training Examination (ABSITE). The survey specifically asked residents in both study arms (standard or more flexible policies) why and how often they exceeded duty hour limits. Responses to the survey indicated:

• Interns (PGY-1 or first-year residents) in the flexible policy arm reported working more than 16 hours continuously at least once in a month more frequently than standard policy residents (86 percent vs. 37.8 percent).
• Flexible policy residents overall reported working more than 28 hours at least once in a month more frequently than standard policy residents (PGY 1: 64 percent vs. 2.9 percent; PGY 2-3: 62.4 percent vs 41.9 percent; PGY 4-5: 52.2 percent vs. 36.6 percent). However, this circumstance generally occurred only one to two times per month; 71 percent of residents in the flexible arm reported working more than 28 hours in a shift fewer than three times in a month.
• While flexible policy residents reported working more than 80 hours in a week three or more times in the most recent month more frequently than standard policy residents (19.9 percent vs 16.2 percent), the difference was driven by interns (30.9 percent vs 19.6 percent). There were no significant differences in exceeding 80 hours among all PGY 2-5 residents. [Note: PGY=Postgraduate Year of Training]

With the exception of interns working more than 16 hours in a shift, most flexible policy residents reported either not using flexibility or doing so only one to two times in a recent month. The most common reasons reported for extending duty hours were:

• facilitating care transitions (76.6 percent)
• stabilizing critically-ill patients (70.7 percent)
• performing routine responsibilities (67.9 percent)
• operating on patients known to the trainee (62.0 percent)

Interns reported more frequently extending shifts to take care of routine responsibilities, complete documentation and rounds with the team, whereas senior residents more frequently reported staying to stabilize a critically ill patient, operate on a patient known to them, or return to work because of a patient's worsening condition. Nearly half of interns in the flexible arm also reported staying longer to attend educational (didactic) sessions.

"These data show that residents' extending of work shifts beyond standard limits occurred infrequently and very selectively," said FIRST Trial principal investigator Karl Y. Bilimoria, MD, MS, FACS, Director of the Surgical Outcomes and Quality Improvement Center at Northwestern University Feinberg School of Medicine, Chicago. "Residents in the flexible arm worked additional hours selectively as needed within the 80-hour workweek; there is no indication that longer shifts were routinely used or abused."

In a separate study, the FIRST Trial researchers also looked specifically at duty hour violations among residents who fell under the current standard policies. They analyzed survey data collected from all residents who completed the 2015 ABSITE, excluding those in the flexible policy arm. These residents were asked about their perceptions of the effect of current duty hour limits on patient safety and how often they violated these limits. Although many factors contribute to patient safety, one often cited issue is "workload compression" due to time-limited shifts.²

In total, 4,554 trainees from 184 programs were included in the analysis, including programs that did not participate in the FIRST Trial. Key findings include the following:

• Just over 25 percent of trainees felt that the current ACGME duty hour policies negatively affected patient safety. Senior residents more frequently perceived that duty hour restrictions negatively influenced patient safety than junior residents and interns (PGY 1: 18.5 percent, PGY 2-3: 22.6 percent, PGY 4-5: 31.0 percent; p<0.001).
• In addition, 23 percent of residents under current policies reported frequent (at least three times per month) duty hour violations. Junior residents reported the highest rate of frequent violations compared to interns and senior residents (PGY 1: 21.7 percent, PGY 2-3: 24.8 percent, PGY 4-5: 22.0 percent; p=0.07).
• Overall, trainees with negative perceptions of how current duty hours affect patient safety reported frequent duty hour violations more often than those with neutral/positive perceptions (32.7 percent vs. 20.0 percent, p<0.001).

The findings of both of these studies closely mirror the recommendations of an ACGME task force that were made available for public comment on November 4. The proposed revised standards strengthen the 80-hour work week and eliminate a separate 16-hour shift limit for first-year residents.

"Flexibility appears to be used selectively by residents for reasons beneficial to patient care and resident training," said Dr. Bilimoria. "Moreover, these data identify areas that need to be monitored and enforced more closely (e.g., 80-hour work week requirement) if flexibility is to be implemented in surgical residency programs nationally."

"Data from these studies shows clearly that residents are careful in how they apply flexibility to their work hours," said Frank R. Lewis, MD, FACS, Executive Director, American Board of Surgery. "Residents want to provide high-quality patient care; they are using flexible hours to help do this."

"This new analysis shows that when surgical residents have some flexibility with their work hours, they choose to devote their time to important activities that safeguard and benefit their patients," said David B. Hoyt, MD, FACS, Executive Director, American College of Surgeons. "These activities also contribute to their education and training experience and to their professionalism."

Four other studies using FIRST Trial data have also been published on the Journal of the American College of Surgeons website. These studies examine gender differences in duty hour perceptions among residents; differences in ABS exam score results; differences in patient length of stay; and perceptions of residents and program directors based on one-on-one qualitative interviews.

On November 14, another FIRST Trial analysis was released showing U.S. general surgery residents strongly prefer work hour policies that allow them the flexibility to work longer when needed to provide patient care over standard, more restrictive work schedules. A striking 86 percent of surgical residents preferred flexible duty (work) hour policies over standard duty hours, or had no preference.