I Say “Tomato,” You Say “Tomato”: Interpreting The Results Of The FIRST Randomized Controlled Trial On Resident Duty Hours

Resident Duty Hours: In a large national cluster randomized controlled trial (N= 4330 general surgery residents in 117 residency programs), Bilimoria et al report whether strict adherence to the standard ACGME resident duty hour rules versus flexible duty hours, while maintaining same total weekly work hours, impacts patient outcomes. Much of the criticism about ACGME duty hour regulations has to do with lack of robust data to support stringent duty hour regulations, so the results of this rigorously designed study were much anticipated. In analysis of data from 138,000 patients during the 1 year study period, the rates of death or serious complications were no different in the 2 study groups (9.1% in flexible group vs 9.0% in standard group, p =0.92). Self reports of having to leave during an operation or hand off active patient issues were lower in the flexible policy group, but there were no significant differences in resident perception of personal or patient safety or satisfaction with educational quality. Do the results of this trial give ammunition to the critics of ACGME duty hours to go back to the good old days? Not so fast. Lack of a significant difference in patient outcomes or resident satisfaction actually should lend support to both the proponents and opponents of the standard duty hours. But before one makes a definitive conclusion, it’s worth pointing out that the changes in duty hours occurred in the setting of increasing attending supervision. In order to conclude there is no difference in patient outcomes or quality of education, a study with longer duration of follow up tracking patient outcomes after these residents have graduated might provide more robust evidence. — Sarang Kim, MD

Senior Resident Perspective:   As an intern, I often felt that the 16-hour limit interfered with my ability to spend sufficient time with my patients. I was expected to be efficient, but the patients were complex and much of my time was sequestered behind a computer. I found night float challenging since it required evaluating new complaints on patients I had never met or laid hands on during the day. As a senior resident, I’ve found 24 hour calls tiring, but I appreciate the opportunity to see patients through critical situations and immediately learn from my decision making.  The time off after a 24-hour call has been important to my well-being and the required day off every seven has enabled me to recharge and enjoy life with family and friends.  Ultimately, I’m not so sure that my postmillennial generation of learners would ever want to go back to the sort of hours their attendings once endured, but it appears that some flexibility might not be so bad. — Madeline Sterling, MD, MPH

Bilimore et al. National Cluster Randomized Controlled Trial of Duty-Hour Flexibility in Surgical Training.  NEJM 2016;374:713-27.

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