Surgery Residents Use Flexible Hours to Enhance Patient Care

Marcia Frellick

November 25, 2016

When surgical residents choose to extend their work hours, they do so selectively and to enhance patients' safety, two new studies indicate.

Karl Y. Bilimoria, MD, director of the Surgical Outcomes and Quality Improvement Center at Northwestern University Feinberg School of Medicine in Chicago, Illinois, and colleagues conducted a survey in conjunction with the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial.

The national multicenter study started with the 2015 to 2016 academic year and compared patient complication rates after surgeries performed by residents with flexibility in shift hours vs those working under standard duty hour restrictions.

Results published earlier this year, reported in Medscape Medical News, showed no difference in patient outcomes and in resident perception of their well-being and quality of education. Residents did say that some aspects of care and of their training improved when they had flexibility in hours.

These two new studies explore when and why the residents chose to extend their work hours beyond those recommended. The studies were published online November 21 in the Journal of the American College of Surgeons.

In the first study, a total of 3795 residents from 117 residency programs in the FIRST trial completed the survey in January 2016 as part of the American Board of Surgery In-Training Examination (ABSITE). Response rate was 99%.

Flexible-policy residents reported that the three most common reasons they chose to work extended hours in a shift were facilitating care transitions (76.6%), stabilizing critically ill patients (70.7%), and performing routine responsibilities (67.9%).

The researchers grouped trainees by postgraduate year (PGY): interns (PGY1), junior residents (PGY2-3), and senior residents (PGY4-5).

Reasons for working the longer hours differed with experience. Interns reported more frequently working longer hours to handle routine tasks, finish documentation, and complete rounds, although senior residents more frequently reported working longer hours to stabilize a critically ill patient or operate on a patient they knew, or because they returned to work when a patient's condition worsened.

Flexible-policy interns worked more than 16 hours continuously at least once in a month more frequently than those working under standard policy (86% vs 37.8%), but interns aside, most flexible-policy residents reported either not using the flexibility or using it only once or twice in a recent month.

Flexible-policy residents worked more than 28 hours once in a month more frequently than standard policy residents.

Table.

Postgraduate Year of Training Flexible vs Standard
Year 1 64% vs 2.9%
Years 2 - 3 62.4% vs 41.9%
Years 4 - 5 52.2% vs 36%

However, this most frequently occurred once or twice per month.

Second Study Examines Duty Hour Violations

In a separate study, researchers from the FIRST Trial also examined duty hour violations among residents. They looked at survey responses from residents who completed the 2015 ABSITE, excluding those in the flexible-hours policy group.

The survey asked residents about whether they thought current duty hour limits set by the Accreditation Council for Graduate Medical Education (ACGME) affected patient safety and how often they violated these limits.

The analysis included 4554 trainees from 184 programs. Among the findings were that junior residents reported the highest rate (at least three times a month) of duty hour violations (24.8%). The violation happened at rates among interns at a rate of 21.7%, and among senior residents at 22.0%.

The survey also found that 25.3% of surgical trainees thought shift restrictions reduced patient safety.

Those who felt that way reported frequent duty hour violations more often than those with neutral or positive perceptions.

This study may have advantages over previous studies. Previous studies were conducted through ACGME surveys, and there have been "concerns about falsification," the authors write.

"This survey, completed outside of the ACGME annual survey and performed anonymous to our study team and each respective program, may provide an accurate and honest assessment of the current landscape of duty hour compliance," they write.

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

Findings of both studies support the recommendations of an ACGME task force that were proposed for public comment on November 4. The task force recommended strengthening the 80-hour work week limitations, but scrapping the 16-hour shift limit for first-year residents.

The FIRST Trial received funding from the American Board of Surgery, which administered the resident survey; the American College of Surgeons; and ACGME. The authors have disclosed no relevant financial relationships.

J Am Coll Surgeons. Published online November 21, 2016. Study 2 abstract, Study 2 abstract

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