A national survey conducted as part of
the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST)
Trial suggested that United States general surgery residents are selectively making the choice to
work additional hours when needed to manage critical stages in patient
‘Many residents selectively work more hours to facilitate care transitions, stabilize critically ill patients, and other important reasons, suggested a new study.’
The trial, the first-ever national multicenter randomized study
of resident duty (work) hour policies, began with the 2015-2016 academic
While initial results of the trial published earlier this year
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%) as part of the American Board of Surgery In-Training
). 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
- 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% vs.
- 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% vs. 2.9%; PGY 2-3: 62.4% vs
41.9%; PGY 4-5: 52.2% vs. 36.6%). However, this
circumstance generally occurred only one to two times per month; 71% 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% vs 16.2%), the
difference was driven by interns (30.9% vs 19.6%). There
were no significant differences in exceeding 80 hours among all PGY 2-5
[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%)
- stabilizing critically-ill patients (70.7%)
- performing routine responsibilities (67.9%)
- operating on patients known to the trainee (62%)
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, 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
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% 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%,
PGY 2-3: 22.6%, PGY 4-5: 31.0%; p<0.001).
- In addition, 23% 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%, PGY 2-3:
24.8%, PGY 4-5: 22.0%; 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% vs.
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, 2016. The proposed revised standards strengthen
the 80-hour work week and eliminate a separate 16-hour shift limit for
"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
"Data from these studies shows clearly that residents are careful in how
they apply flexibility to their work hours," said Frank R. Lewis, Executive Director, American Board of Surgery. "Residents want to
provide high-quality patient care; they are using flexible hours to help
"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, 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, 2016, 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%
of surgical residents preferred flexible duty (work) hour policies over
standard duty hours, or had no preference.