General surgery residents prefer flexible work hours for patient care, education

CHICAGO (November 14, 2016): 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, according to results from a national survey conducted as part of the landmark Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial. In fact, this preference for flexibility becomes even stronger as residents progress through their five years of training. The new analysis—a survey of more than 95 percent of the 3,700 surgeons in training who participated in the FIRST Trial—found that a striking 86 percent of surgical residents preferred flexible duty (work) hour policies over standard duty hours, or had no preference.

The survey findings appear online as an "article in press" on the Journal of the American College of Surgeons website in advance of print publication.

Some controversy has recently surrounded resident duty hour policies and the FIRST Trial's examination of adding flexibility to residents' work schedules. However, until the FIRST Trial, high-quality, national data did not exist regarding the impact of these policies on patient care and resident well-being. The FIRST Trial was the first national randomized trial to compare standard surgical resident duty hour requirements with more flexible policies. The proposal on November 4 from a task force of the Accreditation Council for Graduate Medical Education (ACGME) for changes to resident duty hour policies was prompted in part by results of the FIRST Trial.¹

During the FIRST Trial, 59 general surgery residency programs adhered to standard duty hour policies, which the ACGME established in 2003 and 2011. The other 58 programs tested a flexible policy that waived certain ACGME rules on maximum shift lengths and mandatory time off between shifts, to allow the residents the flexibility to stay longer when needed to provide patient care or for educational opportunities. However, both groups were limited to an 80-hour workweek averaged over four weeks.

Findings of the FIRST Trial² published earlier this year in the New England Journal of Medicine demonstrated that easing current restrictions on surgical residents' schedules to allow for some flexibility did not worsen patient outcomes among general surgical patients and did not adversely affect overall resident well-being. Rather, residents in the flexible arm of the study noted several benefits with respect to patient care, continuity of care, and resident training.

This new survey analysis uncovers additional critical findings, as the researchers set out to determine if surgical residents within each study arm had different perceptions of patient safety, continuity of care, resident education and clinical training, and resident well-being at three distinct levels of training: interns (PGY-1), junior residents (PGY-2, PGY-3), and senior residents (PGY-4, PGY-5). [Note: PGY = Postgraduate Year of Training.]

"A striking finding from this new analysis is that the vast majority of residents at all levels preferred to work under flexible duty hour policies," 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. "If residents were in the flexible study arm, they appreciated flexible duty hours even more and expressed an even stronger preference for working under flexible duty hour policies."

During the FIRST Trial, survey data were collected in collaboration with the American Board of Surgery, which administered the survey to all residents who took the American Board of Surgery In-Training Examination (ABSITE^®) in January 2015.

Key findings in the major domain areas of the survey follow.

Resident Duty Hour Preferences

• Overall, residents expressed a strong preference for flexible duty hour polices, particularly if they had already experienced flexibility in their training.
• Only 14 percent of residents overall expressed a preference for training under standard duty hour policies.
• At all PGY levels, residents either expressed a preference for flexible training under flexible duty hour policies or no preference. Preference levels reported were: interns, 84.82 percent; junior residents, 84.04 percent; and senior residents, 88.93 percent (p<0.001).

Patient Safety and Continuity of Care

• Dissatisfaction with patient safety was higher in all three training levels in the standard hours group, with 22.7 percent of interns reporting dissatisfaction compared with only 10.8 percent of the interns in the flexible hours group.
• The degree of dissatisfaction grew for junior and senior level residents, with 35 percent of senior residents training under standard hours dissatisfied with patient safety, compared with only 12.7 percent of senior residents working flexible hours.
• During the first year of training, 58.5 percent of interns who worked in the standard policy group expressed dissatisfaction with continuity of care issues, while only 10.5 percent of the interns in the flexible group were dissatisfied.
• For senior residents, 61 percent in the standard group reported dissatisfaction with continuity of care, compared with 25.6 of the senor residents working flexible hours.
• Having to leave the hospital and miss an operation to comply with duty hour restrictions was a notable issue for residents in both groups. The most evident differences were reported among the interns, who said they had to leave during an operation far more frequently under standard policy (17.9 percent) compared with those in the flexible policy group (6.9 percent).
• Standard policy junior and senior residents also reported having to leave an operation at a rate that was two-fold greater than residents working flexible hours.

Resident Education and Clinical Training

• With each additional year of training, fewer residents in the flexible-policy group expressed dissatisfaction with the quality of their residency education.
• Dissatisfaction in this area dropped from 15 percent of interns to less than 10 percent of junior residents and below 9 percent of senior residents, although study authors note this difference was not statistically significant.

Resident Well-Being

• Residents working in programs with flexible duty hours were more likely than those using the standard policy to respond that duty hour policies had a negative effect on well-being, in areas such as rest and leisure time. The flexible policy waived rules on maximum shift lengths and time off.
• Perceptions of the flexible policy impacting well-being were most pronounced in the interns and significantly decreased as training level increased.
• Thirty-eight percent of interns and nearly one-fourth of junior residents felt that the flexible duty hour policy left less time for rest. Only 16 percent of senior residents who had more responsibility for patient care felt that way.

These survey findings follow 10 days after an ACGME task force issued recommendations regarding changes to its Common Program Requirements, which establish uniform standards for all ACGME-accredited US residency and fellowship programs. A 45-day public comment period is now underway. A key part of the recommendations propose greater flexibility in resident work hours as generally tested in the FIRST Trial, including allowing first-year residents to work 24-hour shifts within the 80-hour workweek—like all other residents—rather than the 16-hour shifts presently allowed for this group.¹ An ACGME task force made these recommendations based in part on results of recent studies, including the FIRST Trial.

"These survey findings should be very beneficial in helping to inform future duty hour policies. Overall, it is critically important to know what surgical residents think about the duty hour policies at their institutions," Dr. Bilimoria said. "Residents are at the front line of patient care and are the best positioned to let us know whether flexibility facilitates patient safety, continuity of care, and better training."

"Surgical residents have demonstrated a clear preference for more flexibility within the 80-hour workweek," said Frank R. Lewis, MD, FACS, Executive Director, American Board of Surgery. "Moreover, this flexibility has been shown to prevent disruptions in patient care and surgical education."

"We already know that flexible training hours do not harm patients and improve residents' educational experience," said David B. Hoyt, MD, FACS, Executive Director, American College of Surgeons. "The next step is for residency programs to achieve a proper balance between safely caring for patients and training residents to an optimal level, while considering the well-being of the resident physicians who provide that care."