Surgery residency program directors believe flexible duty hours improve continuity of care

The FIRST Trial, presented before the Academic Surgical Congress in Jacksonville, Fla., and published online in the New England Journal of Medicine on February 2, demonstrated that easing restrictions on residents' work schedules did not adversely affect patient outcomes. The survey of program directors, published online in the Journal of the American College of Surgeons in advance of print publication, was administered to all 117 general surgery residency programs that participated in the FIRST Trial.

"Findings from this survey of program directors are consistent with the sentiments of residents who participated in the FIRST Trial, which showed that there was no difference in patient safety or outcomes when surgical residents had flexible working hours. Residency program directors in this survey in fact believed that flexible duty (work) hours were likely to improve patient safety," said lead study investigator Anthony D. Yang, MD, FACS, an assistant professor of surgery, Northwestern University Feinberg School of Medicine, Chicago.

The survey collected observations from directors of 59 general surgery residency programs that adhered to the "Standard Policy" regarding resident work hours and 58 programs that tested a "Flexible Policy." Standard Policy, which was established by the ACGME in 2011, places additional restrictions on maximum shift length for first year residents and increases the required time off after overnight call shifts for residents beyond the initial duty hour reforms initiated by the ACGME in 2003. Flexible Policy relaxes these requirements.

"The survey was completed by a large sample of surgery residency program directors in the U.S who are responsible for ensuring that residents meet duty hour requirements and have a good educational experience. Gaining their opinions and perceptions is important to inform any change in duty hour policy," Dr. Yang said.

Although created to minimize concerns about patient safety and residents' well-being, the current ACGME policy on duty hours has been called into question in recent years. Previous surveys of surgical residency program directors have raised concerns that the work hour restrictions prevent residents from witnessing the evolution of a patient's clinical course of illness, reduce residents' preparedness for assuming senior clinical roles, and limit residents' ability to achieve specialty-specific competency goals.

"Because residents must adhere to a rigid work schedule, they may have to leave the hospital even when they are still actively caring for patients. Such work hour restrictions may interfere with their ability to care for patients through the entire inpatient episode and to fully participate in operations on patients they have evaluated to the point where they often have to leave in the middle of an operation," Dr. Yang said.

The current survey gathered the perceptions of surgical residency program directors in three areas:

1. the ways in which residents used additional flexibility in duty hours
2. the effects of flexible versus standard duty hours on resident education and well-being
3. the effects of a hypothetical shift to flexible duty hours nationwide

A high percentage of directors in programs in the Flexible Policy arm said that their residents used the flexible time to engage in direct patient care. All 58 directors (100 percent) stated that residents spent flexible duty hours stabilizing critically ill patients or completing operations they had started. Fifty six (97 percent) said that residents spent time assisting with transitions in care; 55 (95 percent) said the time was used by residents to operate on a patient on their clinical service or perform an uncommon or complex operation that was important to their development as a surgeon.

Sixty-nine percent of these program directors also felt that flexible duty hours had a positive effect on patient safety. In contrast, none of the program directors in the Standard Policy arm felt that standard duty hours had a positive effect on patient safety, and 14 percent felt that current duty hour restrictions had a negative effect on patient safety.

A majority of all of the program directors felt that a shift to flexible duty hours would positively affect patient safety (72 percent), continuity of care (94 percent), quality of resident education (84 percent), and resident well-being (56 percent).

"Restrictions on residents' duty hours were implemented with good intentions, but they take away some of the residents' choices regarding how they care for patients and their education. According to the perceptions of surgical residency program directors, giving some of that choice back to the residents does not hurt, and probably helps patients and residents," Dr. Yang said.

"These perceptions confirm the findings of the FIRST Trial, which showed that flexible duty hours are safe for patients and have some benefits for residents. This flexibility provides patients with greater continuity of care and allows residents to take on a greater commitment to their patients," said ACS Executive Director David B. Hoyt, MD, FACS.

"The results of this survey reinforce the findings of the FIRST Trial that more flexible work hours enhance continuity of care, prevent disruptions in patient care and surgical education, and allow residents to make the patient, rather than the clock, their prime focus." said ABS Executive Director Frank R. Lewis Jr., MD, FACS."