Limiting Resident Hours Ups Satisfaction, No Effect on Education

Veronica Hackethal, MD

March 28, 2018

Residents with limited work hours report more satisfaction with their training and work–life balance than those with flexible hours and longer shifts, according to results from the Individualized Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial.

The study, published online March 20 in the New England Journal of Medicine, also shows that limiting residents' work hours does not appear to affect educational outcomes.

"Many educators have worried that the shift work created by limited duty hours will undermine the training and socialization of young physicians," principal investigator David Asch, MD, from the University of Pennsylvania in Philadelphia, said in a press release.

"Educating young physicians is critically important to health care, but it isn't the only thing that matters. We didn't find important differences in education outcomes, but we still await results about the sleep interns receive and the safety of patients under their care," he added.

The issue goes back at least to 2003, when the Accreditation Council of Graduate Medical Education (ACGME) limited resident work hours to 30-hour shifts and 80-hour work weeks. In 2011, the ACGME further limited shifts to 16 hours for first-year residents (interns).

Before these changes, resident hours were generally unrestricted. Ninety-plus hour work weeks and 36-hour shifts were often the norm. Program directors often justified these long hours by saying they contributed to continuity of care and helped train physicians to function successfully while sleep-deprived and under pressure.

Early evaluations showed that the restriction in work hours did not significantly affect patient outcomes. Yet program directors still reported that the quality of training and professional development of residents may be suffering. And they continued to voice concerns about the safety and quality of patient care.

To find out what is really going on, researchers conducted a randomized trial at 63 internal medicine residency programs across the United States between July 2015 and June 2016.

They assigned 31 programs to standard work hours with limited work hours according to the 2011 ACGME policies: maximum 16-hour shifts for interns, maximum 28-hour shifts for more senior residents, at least 8 hours off between shifts, maximum 80-hour work weeks, and at least 1 day off every 7 days. The other 32 programs were assigned to use flexible work hours, with maximum 80-hour work weeks and 1 day off every 7 days, but no restrictions on shift length or mandatory time off between shifts.

For the current analysis, 23 trained observers followed the daily shifts of 80 interns (44 in flexible programs, 36 in standard programs) to evaluate activities and time spent in patient care vs education. The researchers also assessed medical knowledge by comparing scores on the American College of Physicians second-year in-training exam, and they surveyed trainees and program directors to assess their perceptions about satisfaction, education, burnout, work intensity, and continuity of care.

Results showed no significant differences in time spent on direct patient care for trainees in flexible programs (13.0%) vs standard programs (11.8%; P = .21). Residents in both types of programs also spent the same amount of time on education: 7.3 hours per shift for both (P > .99).

Likewise, residents in flexible and standard programs had similar scores on in-training exams, even after adjusting for baseline scores that varied largely across programs (P < .001 for noninferiority). In 2016, second-year residents in flexible programs had average scores of 68.9%, and those in standard programs had scores of 69.4%.

However, differences emerged when it came to satisfaction with work–life balance and education.

Compared with interns in standard programs, those in flexible programs were almost 2.5 times more likely to report dissatisfaction with their overall well-being (odds ratio [OR], 2.47; 95% confidence interval [CI], 1.67 - 3.65) and were more than six times more likely to report dissatisfaction with how the program affects their personal lives with friends and family (OR, 6.11; 95% CI, 3.76 - 9.91). They also reported more than 1.5 times more dissatisfaction with the overall quality of education (OR, 1.67; 95% CI, 1.02 - 2.73).

Yet both groups reported similarly high rates of burnout: 79% for flexible programs and 72% for standard programs.

In contrast, program directors of standard programs were more likely than those of flexible programs to report dissatisfaction with various aspects of training. For example, directors of standard programs reported more dissatisfaction with the quality and frequency of patient handoffs and the adequacy of bedside teaching, as well as the ability of interns to manage patients they admit and effectively perform their clinical duties.

"The takeaway is that interns were overall less satisfied with the flexible policies and the program directors were less satisfied with the standard approach," senior author Judy Shea, PhD, from the University of Pennsylvania said in a press release.

Principal investigator Asch added: "The residents are telling us something and program directors should listen carefully."

In a linked editorial, Graham McMahon, MD, MMSC, from the ACGME in Chicago, agreed. "It is increasingly clear that many residents and physicians are focused on surviving rather than thriving."

The response of residents in the iCOMPARE trial may provide the "clearest signal yet of the distress they feel," he added, although the results may ultimately help improve the situation.

He went on to draw attention to the high rates of burnout for all residents, "substantially" more overall dissatisfaction for residents in standard programs, and the mismatch between the responses of residents and program directors, suggesting the latter may be out of touch with their residents.

He concluded: "The contribution of the iCOMPARE trial may not be the determination of whether flexible or standard duty hours are preferred, but rather whether health system and education leaders hear the sentinel plea of residents to reform our clinical learning environments to prioritize people. The response of our profession to these clear warning signs should become the durable legacy of this trial."

The study is ongoing. Results on patient mortality and intern sleep and alertness are expected in early 2019.

The study was funded by the National Heart, Lung, and Blood Institute and the ACGME. The first author is a member of the ACGME Internal Medicine Review Committee. One or more coauthors reports grants, personal fees, and/or other nonspecified potential conflicts of interest from one or more of the following: National Institutes of Health (National Heart, Lung, and Blood Institute), Medicalis, SEA Medical Systems, EarlySense, CDI (Negev), ValeraHealth, MDClone, American Board of Surgery, Accreditation Council for Graduate Medical Education, American College of Surgeons, and ACGME. Dr McMahon reports receiving fees from the ACGME.

N Engl J Med. Published online March 20, 2018. Article full text, Editorial full text

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