Flexibility In Duty Hour Requirements Research Articles

A National Mixed-Methods Evaluation of Preparedness for General Surgery Residency and the Association With Resident Burnout

Differences in medical school experiences may affect how prepared residents feel themselves to be as they enter general surgery residency and may contribute to resident burnout. To assess preparedness for surgical residency, to identify factors associated with preparedness, to examine the association between preparedness and burnout, and to explore resident and faculty perspectives on resident preparedness. This cross-sectional study used convergent mixed-methods analysis of data from a survey of US general surgery residents delivered at the time of the 2017 American Board of Surgery In-Training Examination (January 26 to 31, 2017) in conjunction with qualitative interviews of residents and program directors conducted as part of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial. A total of 262 Accreditation Council for Graduate Medical Education-approved US general surgery residency programs participated. Survey data were collected from 3693 postgraduate year (PGY) 1 and PGY2 surgical residents (response rate, 99%) and 98 interviews were conducted with residents and faculty from September 1 to December 15, 2018. Data were analyzed from June 1, 2017, to February 15, 2018. Hierarchical regression models were developed to examine factors associated with preparedness and to assess the association between preparedness and resident burnout. Qualitative interviews were conducted to identify themes associated with preparation for residency. Of the 3693 PGY1 and PGY2 residents who participated (2258 male [61.1%]), 1775 (48.1%) reported feeling unprepared for residency. Approximately half of surgery residents took overnight call infrequently (≤2 per month) during their core medical student clerkship (1904 [51.6%]) or their subinternship (1600 [43.3%]); 524 (14.2%) took no call during their core clerkship. In multivariable analysis, residents were more likely to report feeling unprepared for residency if they were female (odds ratio [OR], 1.34; 95% CI, 1.15-1.57) or did not take call as a medical student (OR for 0 vs >4 calls, 2.72; 95% CI, 2.10-3.52). Residents who did not complete a subinternship were less likely to report feeling prepared for residency (OR, 0.68; 95% CI, 0.48-0.96). Feeling adequately prepared for residency was associated with a nearly 2-fold lower risk of experiencing burnout symptoms (OR, 0.57; 95% CI, 0.48-0.68). In interviews, the dominant themes associated with preparedness included the following: (1) various regulations limit the medical school experience, (2) overnight call facilitates preparation and selection of a specialty compatible with their preferences, and (3) adequate perceptions of residency improve expectations, resulting in improved preparedness, lower burnout rates, and lower risk of attrition. In this cross-sectional study, the perception of feeling unprepared was associated with inadequate exposure to resident responsibilities while in medical school. These findings suggest that effective preparation of medical students for residency may result in lower rates of subsequent burnout.

Culture of Surgical Residency: Findings from the Flexibility in Duty Hour Requirements for Surgical Trainee (FIRST) Trial Qualitative Study

Johnson, Julie K. MSPH, PHD; Dahlke, Allison R. MPH; Hewitt, Daniel B. MD, MPH; Kreutzer, Lindsey MPH; Love, Remi R. MPPA; Bilimoria, Karl Y. MD, MS Author Information

Thinking clearly about the FIRST trial: addressing ethical challenges in cluster randomised trials of policy interventions involving health providers

The ethics of the Flexibility In duty hour Requirements for Surgical Trainees (FIRST) trial have been vehemently debated. Views on the ethics of the FIRST trial range from it being...

Training Surgeons in the Current US Healthcare System: A Review of Recent Changes in Resident Education

This review highlights research focusing on the quality of surgical education within the current constraints of healthcare delivery in the United States. The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial has provided the first evidence from a randomized controlled trial regarding duty hour regulations. Results of the FIRST trial were instrumental in the 2017 ACGME Common Core Requirement changes that allow for more flexibility in clinical hours to encourage professionalism and accommodate both patient care and educational opportunities. Research focusing on resident autonomy has highlighted multiple factors necessary to ensure appropriate graduated levels of responsibility during training. Lastly, competency-based education provides a structured format to ensure minimum standards of performance in all graduates. More flexible hours, increasing autonomy, and competency-based evaluations may help improve confidence and competence of surgery residency graduates.

Estimation of Population Average Treatment Effects in the FIRST Trial: Application of a Propensity Score-Based Stratification Approach.

To estimate and compare sample average treatment effects (SATE) and population average treatment effects (PATE) of a resident duty hour policy change on patient and resident outcomes using data from the Flexibility in Duty Hour Requirements for Surgical Trainees Trial ("FIRST Trial"). Secondary data from the National Surgical Quality Improvement Program and the FIRST Trial (2014-2015). The FIRST Trial was a cluster-randomized pragmatic noninferiority trial designed to evaluate the effects of a resident work hour policy change to permit greater flexibility in scheduling on patient and resident outcomes. We estimated hierarchical logistic regression models to estimate the SATE of a policy change on outcomes within an intent-to-treat framework. Propensity score-based poststratification was used to estimate PATE. This study was a secondary analysis of previously collected data. Although SATE estimates suggested noninferiority of outcomes under flexible duty hour policy versus standard policy, the noninferiority of a policy change was inconclusively noninferior based on PATE estimates due to imprecision. Propensity score-based poststratification can be valuable tools to address trial generalizability but may yield imprecise estimates of PATE when sparse strata exist.

Gender-Based Differences in Surgical Residents' Perceptions of Patient Safety, Continuity of Care, and Well-Being: An Analysis from the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial

Little is known about gender differences in residency training experiences and whether duty hour policies affect these differences. Using data from the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial, we examined gender differences in surgical resident perceptions of patient safety, education, health and well-being, and job satisfaction, and assessed whether duty hour policies affected gender differences. We compared proportions of male and female residents expressing dissatisfaction or perceiving a negative effect of duty hours on aspects of residency training (ie patient safety, resident education, well-being, job satisfaction) overall and by PGY. Logistic regression models with robust clustered SEs were used to test for significant gender differences and interaction effects of duty hour policies on gender differences. Female PGY2 to 3 residents were more likely than males to be dissatisfied with patient safety (odds ratio [OR]= 2.50; 95% CI, 1.29-4.84) and to perceive a negative effect of duty hours on most health and well-being outcomes (OR= 1.51-2.10; all p < 0.05). Female PGY4 to 5 residents were more likely to be dissatisfied with resident education (OR= 1.56; 95% CI, 1.03-2.35) and time for rest (OR= 1.55; 95% CI, 1.05-2.28) than males. Flexible duty hours reduced gender differences in career dissatisfaction among interns (p= 0.028), but widened gender differences in negative perceptions of duty hours on patient safety (p<0.001), most health and well-being outcomes (p < 0.05), and outcomes related to job satisfaction (p < 0.05) among PGY2 to 3 residents. Gender differences exist in perceptions of surgical residency. These differences vary across cohorts and can be influenced by duty hour policies.

Association Between Flexible Duty Hour Policies and General Surgery Resident Examination Performance: A Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial Analysis

Concerns persist about the effect of current duty hour reforms on resident educational outcomes. We investigated whether a flexible, less-restrictive duty hour policy (Flexible Policy) was associated with differential general surgery examination performance compared with current ACGME duty hour policy (Standard Policy). We obtained examination scores on the American Board of Surgery In-Training Examination, Qualifying Examination (written boards), and Certifying Examination (oral boards) for residents in 117 general surgery residency programs that participated in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial. Using bivariate analyses and regression models, we compared resident examination performance across study arms (Flexible Policy vs Standard Policy) for 2015 and 2016, and 1 year of the Qualifying Examination and Certifying Examination. Adjusted analyses accounted for program-level factors, including the stratification variable for randomization. In 2016, FIRST trial participants were 4,363 general surgery residents. Mean American Board of Surgery In-Training Examination scores for residents were not significantly different between study groups (Flexible Policy vs Standard Policy) overall (Flexible Policy: mean [SD] 502.6 [100.9] vs Standard Policy: 502.7 [98.6]; p= 0.98) or for any individual postgraduate year level. There was no difference in pass rates between study arms for either the Qualifying Examination (Flexible Policy: 90.4% vs Standard Policy: 90.5%; p= 0.99) or Certifying Examination (Flexible Policy: 86.3% vs Standard Policy: 88.6%; p= 0.24). Results from adjusted analyses were consistent with these findings. Flexible, less-restrictive duty hour policies were not associated with differences in general surgery resident performance on examinations during the FIRST Trial. However, more years under flexible duty hour policies might be needed to observe an effect.

Effect of Flexible Duty Hour Policies on Length of Stay for Complex Intra-Abdominal Operations: A Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial Analysis

Changes to resident duty hour policies in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial could impact hospitalized patients' length of stay (LOS) by altering care coordination. Length of stay can also serve as a reflection of all complications, particularly those not captured in the FIRST trial (eg pneumothorax from central line). Programs were randomized to either maintaining current ACGME duty hour policies (Standard arm) or more flexible policies waiving rules on maximum shift lengths and time off between shifts (Flexible arm). Our objective was to determine whether flexibility in resident duty hours affected LOS in patients undergoing high-risk surgical operations. Patients were identified who underwent hepatectomy, pancreatectomy, laparoscopic colectomy, open colectomy, or ventral hernia repair (2014-2015 academic year) at 154 hospitals participating in the FIRST trial. Two procedure-stratified evaluations of LOS were undertaken: multivariable negative binomial regression analysis on LOS and a multivariable logistic regression analysis on the likelihood of a prolonged LOS (>75th percentile). Before any adjustments, there was no statistically significant difference in overall mean LOS between study arms (Flexible Policy: mean [SD] LOS 6.03 [5.78] days vs Standard Policy: mean LOS 6.21 [5.82] days; p= 0.74). In adjusted analyses, there was no statistically significant difference in LOS between study arms overall (incidence rate ratio for Flexible vs Standard: 0.982; 95% CI, 0.939-1.026; p= 0.41) or for any individual procedures. In addition, there was no statistically significant difference in the proportion of patients with prolonged LOS between study arms overall (Flexible vs Standard: odds ratio= 1.028; 95% CI, 0.871-1.212) or for any individual procedures. Duty hour flexibility had no statistically significant effect on LOS in patients undergoing complex intra-abdominal operations.

Use and Underlying Reasons for Duty Hour Flexibility in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial

The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial randomly assigned surgical residency programs to either standard duty hour policies or flexible policies that eliminated caps on shift lengths and time off between shifts. Our objectives were to assess adherence to duty hour requirements in the Standard Policy arm and examine how often and why duty hour flexibility was used in the Flexible Policy arm. A total of 3,795 residents in the FIRST trial completed a survey in January 2016 (response rate >95%) that asked how often and why they exceeded current standard duty hour limits in both study arms. Flexible Policy interns worked more than 16 hours continuously at least once in a month more frequently than Standard Policy residents (86% vs 37.8%). Flexible Policy residents worked more than 28 hours once in a month more frequently than Standard Policy residents (PGY1: 64% vs 2.9%; PGY2 to 3: 62.4% vs 41.9%; PGY4 to 5: 52.2% vs 36.6%), but this occurred most frequently only 1 to 2 times per month. Although residents reported working more than 80 hours in a week 3 or more times in the most recent month more frequently under Flexible Policy vs Standard Policy (19.9% vs 16.2%), the difference was driven by interns (30.9% vs 19.6%), and there were no significant differences in exceeding 80 hours among PGY2 to 5 residents. 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%), and operating on patients known to the trainee (62.0%). There were differences in duty hours worked by residents in the Flexible vs Standard Policy arms of the FIRST trial, but it appeared that residents generally used the flexibility for patient care and educational opportunities selectively.

Association Between Resident Perceptions of Patient Safety and Duty Hour Violations

Residents are often required to balance whether to adhere to duty hour policies or violate them to care for patients and obtain educational experiences. Little is known about why residents violate duty hour policies and whether there is a relationship between how often residents violate duty hours and concerns about patient safety. Our objective was to assess the association between resident duty hour violations and resident concerns about patient safety. We analyzed survey data collected from surgery residents who completed the 2015 American Board of Surgery In-Training Examination, excluding those in the Flexible Policy arm of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial. Perceptions of how duty hour restrictions affect patient safety were dichotomized as either "positive/neutral" or "negative." Resident duty hour violations in a typical month were separated as "frequently" (≥3 times) or "infrequently" (<3 times). Rates were compared and regression models were used to examine the association between negative perceptions and duty hour violations, adjusting for resident and program-level covariates. Overall, 25.3% of trainees under current policies perceived that current ACGME duty hour policies negatively affected patient safety. This negative perception increased with PGY level (PGY1: 18.5%, PGY2 to 3: 22.6%, PGY4 to 5: 32.0%; p < 0.001). Residents with negative perceptions more often reported frequent duty violations (positive/neutral: 20.0% vs negative: 32.7%; p < 0.001). After adjustment for covariates, a negative perception of how duty hour policies affect patient safety was significantly associated with a higher likelihood of frequent duty hour violations among all trainees grouped together (odds ratio [OR]=1.89; 95% CI, 1.60-2.22), and separately for interns (OR= 2.59; 95% CI, 1.70-3.93), junior (OR=1.62; 95% CI 1.22-2.16), and senior residents (OR= 1.99; 95% CI, 1.54-2.58). Trainees who reported perceiving negative effects of duty hour policies on patient safety were more likely to report frequent duty hour violations.

Exploring Qualitative Perspectives on Surgical Resident Training, Well-Being, and Patient Care

The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial found no difference in patient outcomes or resident well-being between more restrictive and flexible duty hour policies. Qualitative methods are appropriate for better understanding the experience and perceptions of those affected by duty hour regulations. We conducted a pilot qualitative study on how resident duty hour regulations are perceived by general surgery program directors, surgical residents, and attending surgeons who participated in the FIRST Trial. Semi-structured qualitative interviews were pilot tested with program directors, residents, and attendings to examine initial perceptions of the standard and flexible policies implemented during the trial. The transcribed interviews were analyzed thematically using a constant comparative approach and grouped first by study arm and then by level (patient, surgeon, program, and national). More restrictive duty hours were perceived as creating a tension between resident personal and professional well-being. Standard Policy resulted in more transitions, which was perceived as creating vulnerable gaps in patient care. Standard Policy restrictions were seen as particularly challenging for interns and often led to inadequate preparation for promotion and encouraged a shift mentality. In our pilot study, interviewees valued the flexibility afforded in the Flexible Policy arm, as it allowed them to maximize patient safety and educational attainment. Additional qualitative research will expand on program director, resident, and attending perceptions of resident duty hours as well as perceptions of patient safety. Qualitative methods can contribute to the national debate on resident duty hours.

Differences in Resident Perceptions by Postgraduate Year of Duty Hour Policies: An Analysis from the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial

In the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial, there were several differences in residents' perceptions of aspects of their education, well-being, and patient care that differed between standard and flexible duty hour policies. Our objective was to assess whether these perceptions differed by level of training. A survey assessed residents participating in the FIRST trial's perceptions of the effect of duty hour policies on aspects of patient safety, continuity of care, resident education, clinical training, and resident well-being. Hierarchical logistic regression models were used to examine the association between residents' perceptions, study arm, and level of training (interns, junior residents, and senior residents). In the Standard Policy arm, as the PGY level increased, residents more frequently reported that duty hour policies negatively affected patient safety, professionalism, morale, and career choice (all interactions p < 0.001). However, in the Flexible Policy arm, as the PGY level increased, residents less frequently perceived negative effects of duty hour policies on resident health, rest, and time for family and friends and extracurricular activities (all interactions p<0.001). Overall, there was an increase by PGY level in the proportion of residents expressing a preference for training in programs with flexible duty hour policies, and this preference for flexible duty hour policies was even more apparent among residents who were in the Flexible Policy arm (p < 0.001). As PGY level increased, residents had increasing concerns about patient care and resident education and training under standard duty hour policies, but they had decreasing concerns about well-being under flexible policies. When given the choice between training under standard or flexible duty hour policies, only 14% of residents expressed a preference for standard policies.

Ethical Considerations in the Development of the Flexibility in Duty Hour Requirements for Surgical Trainees Trial

Ethical Considerations in the Development of the Flexibility in Duty Hour Requirements for Surgical Trainees Trial

Program Director Perceptions of Surgical Resident Training and Patient Care under Flexible Duty Hour Requirements

The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial was a national, cluster-randomized, pragmatic, noninferiority trial of 117 general surgery programs, comparing standard ACGME resident duty hour requirements ("Standard Policy") to flexible, less-restrictive policies ("Flexible Policy"). Participating program directors (PDs) were surveyed to assess their perceptions of patient care, resident education, and resident well-being during the study period. A survey was sent to all PDs of the general surgery residency programs participating in the FIRST trial (N= 117 [100% response rate]) in June and July 2015. The survey compared PDs' perceptions of the duty hour requirements in their arm of the FIRST trial during the study period from July 1, 2014 to June 30,2015. One hundred percent of PDs in the Flexible Policy arm indicated that residents used their additional flexibility in duty hours to complete operations they started or to stabilize a critically ill patient. Compared with the Standard Policy arm, PDs in the Flexible Policy arm perceived a more positive effect of duty hours on the safety of patient care (68.9% vs 0%; p < 0.001), continuity of care (98.3% vs 0%; p < 0.001), and resident ability to attend educational activities (74.1% vs 3.4%; p < 0.001). Most PDs in both arms reported that safety of patient care (71.8%), continuity of care (94.0%), quality of resident education (83.8%), and resident well-being (55.6%) would be improved with a hypothetical permanent adoption of more flexible duty hours. Program directors involved in the FIRST trial perceived improvements in patient safety, continuity of care, and multiple aspects of resident education and well-being with flexible duty hours.

Development of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial Protocol

Debate continues regarding whether to further restrict resident duty hour policies, but little high-level evidence is available to guide policy changes. To inform decision making regarding duty hour policies, the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial is being conducted to evaluate whether changing resident duty hour policies to permit greater flexibility in work hours affects patient postoperative outcomes, resident education, and resident well-being. Pragmatic noninferiority cluster-randomized trial of general surgery residency programs with 2 study arms. Participating in the study are Accreditation Council for Graduate Medical Education (ACGME)-approved US general surgery residency programs (n = 118), their affiliated hospitals (n = 154), surgical residents and program directors, and general surgery patients from July 1, 2014, to June 30, 2015, with additional patient safety outcomes collected through June 30, 2016. The data collection platform for patient outcomes is the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), thus only hospitals participating in the ACS NSQIP were included. In the usual care arm, programs adhered to current ACGME resident duty hour standards. In the intervention arm, programs were allowed to deviate from current standards regarding maximum shift lengths and minimum time off between shifts through an ACGME waiver. Death or serious morbidity within 30 days of surgery measured through ACS NSQIP, as well as resident satisfaction and well-being measured through a survey delivered at the time of the 2015 American Board of Surgery in Training Examination (ABSITE). A total of 118 general surgery residency programs and 154 hospitals were enrolled in the FIRST Trial and randomized. Fifty-nine programs (73 hospitals) were randomized to the usual care arm and 59 programs (81 hospitals) were randomized to the intervention arm. Intent-to-treat analysis will be used to estimate the effectiveness of assignment to the intervention arm on patient outcomes, resident education, and resident well-being compared with the usual care arm. Several sensitivity analyses will be performed to determine whether there were differential effects when examining only inpatients, high-risk patients, and emergent/urgent cases. To our knowledge, the FIRST Trial is the first national randomized clinical trial of duty hour policies. Results of this study may be informative to policymakers and other stakeholders engaged in restructuring graduate medical training to enhance the quality of patient care and resident education. clinicaltrials.org Identifier: NCT02050789.