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

Bilimoria, Karl Y.; Chung, Jeanette W.; Hedges, Larry V.; Dahlke, Allison R.; Love, Remi; Cohen, Mark E.; Tarpley, John L.; Mellinger, John D.; Mahvi, David M.; Kelz, Rachel R.; Ko, Clifford Y.; Hoyt, David B.; Lewis, Frank

doi:10.1001/jamasurg.2015.4990

Cited by 78 publications

(71 citation statements)

References 28 publications

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“…The study sample included general surgery residents in 117 general surgery residency programs in the U.S. and 151 affiliated hospitals that participated in the FIRST Trial. 7, 8 Programs were randomly assigned to either “Standard Policy,” which required adherence to all current ACGME duty hour requirements, or “Flexible Policy” in which the daily duty hour limits (e.g., 16 hours for interns and 28 hours for senior residents) and minimum time off between shift requirements (8 hours between daily shifts and 14 hours off after a 24-hour call) were waived through a formal waiver from the ACGME. All programs, regardless of study arm assignment, were required to adhere to the requirements regarding the 80-hour work week, one day off in seven, and call no more frequently than every third night.…”

Section: Methodsmentioning

confidence: 99%

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

Blay

Hewitt

Chung

et al. 2017

Journal of the American College of Surgeons

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Background 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 to current Accreditation Council for Graduate Medical Education (ACGME) duty hour policy (Standard Policy). Study Design We obtained examination scores on the American Board of Surgery (ABS) In-Training Examination (ABSITE), Qualifying Examination (QE, written boards), and Certifying Examination (CE, 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 vs. Standard Policy) for 2015 and 2016, and one year of the QE and CE. Adjusted analyses accounted for program-level factors, including the stratification variable for randomization. Results In 2016, 4363 general surgery residents were participants in the FIRST Trial. Mean ABSITE scores for PGY residents were not significantly different between study groups (Flexible Policy vs Standard Policy) overall (mean [SD]: Flexible: 502.6 [100.9] vs. Standard: 502.7 [98.6], p=0.98)) or for any individual PGY levels. There was no difference in pass rates between study arms for either the QE (Flexible: 90.4% vs Standard: 90.5%, p=0.99) or CE (Flexible: 86.3% vs Standard: 88.6%, p=0.24). Results from adjusted analyses were consistent with these findings. Conclusions Flexible, less-restrictive duty hour policies were not associated with differences in general surgery resident performance on examinations during the FIRST Trial. However, additional years under flexible duty hour policies may be needed to observe an effect.

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Section: Methodsmentioning

confidence: 99%

“…8 The unit of analysis was at the resident level. We explored the inclusion of various resident and program level characteristics in the model such as gender, geography, and academic vs non-academic program status.…”

Section: Methodsmentioning

confidence: 99%

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

Blay

Hewitt

Chung

et al. 2017

Journal of the American College of Surgeons

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“…Multiple North American medical commissions have advocated for duty hour circumscriptions including the Bell Commission, which instituted New York State's limit on resident work hours, the Institute of Medicine, the Accreditation Council for Graduate Medical Education (ACGME), and Canada's National Steering Committee on Resident Duty Hours. In 2003 and 2011, the ACGME placed constraints on labor hours by physicians in training mandating a maximum 80-hour work a week, dictating compulsory time off between shifts, and circumscribing on-call periods [14]. In developing the ACGME's 2011 directives, policy makers sought to enhance the safety of patients and to foster learning environments that nurture physicians' professional development by promoting resident respite, wellness, and empathy [7].…”

Section: Medical Commissions Advocate For Duty Hour Restrictionsmentioning

confidence: 99%

The Impact of Fatigue on Medical Error and Clinician Wellness: A Vignette-Based Discussion

Salen¹,

Norman²

2018

Vignettes in Patient Safety - Volume 2

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Fatigue-induced medical errors and complications spark concern in patients, clinicians, and policy makers, as documented by the Institute of Medicine report in 1999 that approximately 100,000 Americans die annually secondary to potentially avoidable injurious events. Over the last 2 decades, multiple organizations have advocated for the implementation of labor hour restrictions to redress physician in training fatigue and enhance patient safety. Advocates for duty hour caps in physician training programs cite the potential for improvements in patient safety, whereas adversaries allege that curtailing duty hours compromises medical education and readiness for solo practice. Sleep deprivation impairs multiple aspects of cognition, function, and capacity, including many aspects essential to the practice of medicine, e.g., cognizance, recollection, and dexterity. Resident physicians' traditional extended duty shifts for 24-30 consecutive hours pose significant hazards not only to patients but also to the physicians in training themselves. Burnout among physicians in training occurs commonly and results from work-related stress characterized by emotional prostration, depersonalization manifest as cynicism and detachment toward patients, and diminution of personal esteem. Curtailed shift duration correlates best with improved patient care of the strategies for managing physician fatigue. Adequate supervision of residents and medical students has the potential to improve resident education and further patient safety. Night float shifts improve resident's well-being in terms of acclimating to a consistent nocturnal schedule. Data supporting capping physician work hours demonstrates evidence of amelioration of fatigue, thereby improving physician's quality of life; evidence supporting duty hour restriction for enhancing patient safety, decreasing medical errors, and physician training, including surgical, is mixed and more nuanced.

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“…3,4 Current duty hour regulations were borne from concern that extreme resident fatigue posed a risk to patient safety. 5,6 After initial ACGME regulations for an 80-hour work week maximum in 2003, duty hours were further restricted in 2011 after the release of an Institute of Medicine report recommending shorter shift lengths for interns and residents.…”

mentioning

confidence: 99%

“…The methods have been described extensively elsewhere. 3 The FIRST trial authors concluded that flexible duty hour policies for surgical residents were noninferior to current ACGME duty hour policies for patient outcomes and resulted in similar resident satisfaction about their overall well-being and education quality. 12 Research to gauge resident and program director (PD) perceptions of duty hour requirements suggests that the 2011 restrictions drove resident dissatisfaction and delayed maturation of residents, brought about challenges surrounding the night float system, and decreased the surgical case volume for residents.…”

mentioning

confidence: 99%

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

Kreutzer

Dahlke

Love

et al. 2017

Journal of the American College of Surgeons

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

Abstract: clinicaltrials.org Identifier: NCT02050789.

Cited by 78 publications

References 28 publications

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

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

The Impact of Fatigue on Medical Error and Clinician Wellness: A Vignette-Based Discussion

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

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