It is exciting to see this landmark study about resident duty hours in the New England Journal of Medicine. The FIRST Trial studied the impact of altering duty hours in surgical trainees on patient care outcomes and resident satisfaction. Researchers from Northwestern University Feinberg School of Medicine, the American College of Surgeons, the American Board of Surgery, and elsewhere, presented their findings at the Academic Surgical Congress meeting earlier today. The Journal published this Online First today, with an accompanying editorial on the topic.
How will the FIRST Trial Affect Residents — and Patients?
As a medical educator, I am always interested in how altering the clinical learning environment affects what physicians in training do, how they learn, and how that impacts patients. Ultimately, what matters most is the last one of these: the impact on patients, which this trial measured through ACS’s National Surgical Quality Improvement Program (NSQIP). The researchers hypothesized that patient outcomes would be no worse than those under the current ACGME duty hour regulations, when shifted to a more flexible model. The research found that specific NSQIP surgical outcomes were essentially unchanged for patients cared for by residents in the usual group (the current duty hour restrictions) and patients cared for by residents in the intervention group. Notably, residents in both groups reported no difference in satisfaction.
So what exactly does this mean? I can see two alternatives for how medical educators could interpret these findings: One, surgical educators might decide to abandon the current duty hours regulations for surgical trainees, introducing more flexible alternatives to the usual duty hour rules. This could mean reducing hours, but it could also mean allowing a resident to complete a surgery even if it required going past a certain hour. Two, medical educators might interpret the findings to mean they can continue to enforce the current duty hours regulations for surgical trainees, since patient care under this system was not worse.
The accompanying NEJM editorial by Dr. Birkmeyer encourages educators to reflect on the entire training process and to interpret the findings within the context of keeping the duty hour restrictions the same to promote optimal resident self-care. He encourages the development of resilient health care systems. Residents should consider the importance of self-care not only for themselves but for the sake of their patients. Educators should also make sure that when training is completed, graduating surgeons are competent to perform the operations they are trained to do; I believe the surgical educator community does an excellent job determining this already.
Surgical Trainees vs. Medical Trainees
I applaud our surgical educator colleagues for looking at duty hours through a scientific lens and studying this process in the form of a trial — but the findings should not be applied to all trainees. It was designed for programs with surgical trainees only; there is another study (currently ongoing) called the iCOMPARE trial looking at duty hour restrictions in medical residency programs, whose findings won’t be known for a while.
As a medical educator myself, I look forward to seeing whether the results of iCOMPARE will be the same or different from those of the FIRST study, especially given the changing paradigm in resident education in this new era.
For more on this topic and today’s findings, follow the tweets at #FirstTrialSurgery.
When I look back on my many years of training to be a Urologist, it now seems so far ago. However, when I really check how many hours a day I put in, I shudder. I hope that the longest time for a Resident to be on duty is no longer then 18 hours and maybe even shortened to 12 hours. I would usually have every other night off but the rest of the time I was on duty and stayed in the various hospitals where I took my training which obviously is way too much time to be on duty. I did it then but I now think that more sensible hours should be incorporated into Residents schedules. .
The way this study was designed is not applaudable. First of all, it was funded by the American College of Surgeons and the ACGME. Secondly, it looked at 100+ hours per week versus the newer 80 hours per week. Both are too many hours. It is like comparing bad to worse. There have been many studies showing that sleep deprivation leads to many medical comorbidities including pre-diabetes. It has also been associated with the mental functioning level of someone legally above the alcohol level associated with a DUI. How come they did not compare normal work hour (<12 hour shifts, <50 hours per week) to the above normal levels? I believe it is because residents are cheap labor. We also deal with some of the most difficult social situations in the country. Also to mention, there is loads of paperwork and documentation residents are required to complete for this group of patients.
As a 3rd year resident, when I have questions about most things in my training, the answer can be found by following the money. Hospitals and legislators are greedy with money. I was on a residency quality council in which our hospital administrators were suppose to show up so that resident representatives could address our concerns with them once a month and have a vote on issues in the hospital. Over 6 months, not a single administrator showed up. A residents representative from surgery, internal medicine, orthopedics, etc showed but everytime each of the administrators had an excuse. Finally, the quality council for disbanded. It was a joke. Residents have no voice and no power. Until, we change that by giving ourselves power (maybe national unions?) then we will never have a voice.
Seth,
Thanks for your comments from the resident perspective. BOTH groups in the trial had to adhere to the TOTAL hours per week regulations. It was the flexibility of adhering to those hours that was different between the two groups. The intervention group did not work 100+ hours. The paper makes this pretty clear.
I am sorry to hear that the linkage between administration and resident perspective isn’t what it could be. My experience has been that hospital and health system leadership is VERY interested in resident comments and are very flexible about including residents in such meetings. The CLER initiative from the ACGME makes this all the more important.