Resident Work Hours and the FIRST Trial Results

Posted by • February 4th, 2016

3Resident duty hours mean something different for everyone. Listen to residents, program directors, investigators, and ethicists discuss the results of the newly published FIRST trial, “National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training,” and its implications for the future of resident education. You’ll hear from the principal investigator of FIRST, Karl Bilimoria, David Asch, principal investigator of the iCOMPARE trial, as well as the surgical and medical residents in the trenches.

If you would like to engage in a discussion of the results of the FIRST trial with the authors, please join us on the NEJM Group Open Forum, now through February 17th.

This podcast is the first in a new series that reflects medicine’s most pressing issues through the eyes of residents. “The House” provides residents with a forum to share their stories from the bedside, where they are learning far more than the lessons of clinical medicine.  Lisa Rosenbaum is a cardiologist at Brigham and Women’s Hospital in Boston, and National Correspondent for the New England Journal of Medicine.  Dan Weisberg is an Internal Medicine Resident, also at Brigham and Women’s Hospital.

4 Responses to “Resident Work Hours and the FIRST Trial Results”

  1. Grant Willis says:

    The thought of a surgery intern not logging more than 7 cases in a year seems ridiculous and unfortunate to me. However, there are some aspects of the concerns of resident education and the impact of work hours restrictions that do not add up to me. I would like to illustrate my point with some hypothetical numbers. Let’s say a relatively small and modestly busy teaching hospital conducts ~3,000 operations in a calendar year. If there are always residents present for the operation, then that means all of the cases that can be logged, were logged by residents for that year. If some surgery residents only logged 7 cases for that year, then that means other residents logged significantly more cases. So there should be some residents who are overtrained in relation to their colleagues. Maybe we don’t need to just look at work hour restrictions when it comes to resident education, maybe there needs to be a more proactive method of equally distributing the operative workload among surgical residents rather than just controlling the time a resident is present at the hospital.

    Is there any reason to think that the work hour restrictions have limited the number of operations performed during a calendar year?

    Furthermore, Surgery looks a lot different today than it did 100 years ago, and I am very excited about what will happen in Surgery during my lifetime. Surgeons have historically been very innovative hard working physicians. It is time for their innovation to become more focused on surgical training. I think it would be interesting for more time and funding to be appropriated towards more realistic surgical simulations for residents to train the technical skill of their trade. I would also like to see initiatives to equally distribute operative cases among surgical residents rather than just increase the amount of time they are physically present in the hospital and just hoping that the numbers will work themselves out on their own.

  2. Shadi Abdel-Rehim says:

    Cutting down working hours is detrimental for surgery training in its current form. To cut hours of surgical training it has to be accompanied with a paradigm shift not only in training structure but also in how surgical services are run and how patient care is delivered. Less hours means residents would get less clinical exposure, and consequently less hands-on experience. The only way to compensate for this is by narrowing resident’s scope of practice and move towards the so called ‘competency based training; where residents are trained to perfect a smaller number of procedures. This is usually justified by the notion that we are moving towards ‘super specialization’ and a surgeon is no longer required to know how to do an appendix before being trained to be a plastic or a neurosurgeon surgeon. Ultimately surgical specialties would entirely dissolve and surgeons would be known as a hand surgeon, a breast surgeon, a head & neck surgeon and so on instead of the current nomenclature. Residency program directors would need to think how to tailor surgical training early on depending on candidate preference. For example ENT, Neuro, Plastics and Maxillofacial trainees wishing to do head and neck surgery in future could be grouped together in one interface training program to learn a mixture of surgical skills that would transform them into a unique group of head & neck surgeons. The same applies for breast surgeons, plastics and general surgeons could be grouped together into one residency program designed to train a competent group of breast surgeons, and so on. The second issue with cutting working hours is the increased number of shifts that would need to be covered. Either more residency spots need to be created or hospitals may find it more feasible to recruit more physician assistants and nurse practitioners to fill the gap. The question remains would super specialization and competency based training will produce a well rounded surgeons who are able to further drive surgical specialties. I don’t think this study or any other studies at the moment can answer this question. Only time would tell if we are moving with surgical training in the right direction or not and whether cutting hours and implementing new training methods would results in more competent surgeons. One thing to keep an eye for is the rate of malpractice suits over the next 10-20 years as a marker of surgeons’ competency and patient satisfaction and see if the new style training would result in fewer or more law suits filed against surgeons who once served as residents under more social hours!

  3. Cory Parks says:

    It’s unfortunate that the data for a lot of these trials, especially for the surgical ones, don’t have a lot of data fidelity. Many surgical programs, mine and the program’s of several friends at other institutions (all of which have been included in one duty hour trial or another), have rampant “cheating” on duty hour reporting, contaminating the results, especially for the control arms. For years since the change in the restrictions, the culture has been “report 80 hours, work however many it takes” with not necessarily subtle hints at retaliation if that doesn’t happen. Many of us either have personally or know of someone who has worked many, many hours over-shift without reporting. If your shift is 30 minutes from being over but your patient is going to the OR, you are expected to be there. No one asks about your hours, and you know better than to say. And I have never heard of someone leaving a case midway through just because their shift was over, I sure haven’t. Many of the “non-inferior” findings between controls and flexible methods can be attributed to there being little difference between the groups in practice, other than the flexible model being more open about their hours.

  4. Jeffrey Wilson says:

    I am a PGY3 IM resident in Brooklyn, NY. Let me start by saying that I am single and I have no kids. I began residency thinking the schedule would be difficult to handle. I was wrong. Sure, I put in many 75-80hr weeks but I had no problems with that. I still had a respectable social life. My father went through residency and fellowship so I was prepared. My twin brother also spent his PGY1&2 years at the same program in Brooklyn before transferring to a Midwestern program for personal/relationship reasons. I was shocked when he told me residents had nowhere near the workload As compared to Brooklyn.

    For the most part, I firmly believe society has softened and become more entitled. This has crewed into the medical world and declining reimbursements have progressed the sentiment. As a result, medical (and especially surgical) residents finish their training with less experience and more doubt about their ability to care for patients on their own.

    The benefits of easy resident life come with significant disadvantages. One possible solution could be to have a weekly hour ceiling where some residents (like me) could work longer shifts for fewer days while other residents (like the psych resident) can work more days and shorter shifts or train for a greater amount of time.

    One thing to keep in mind. If you’re starting residency, some things should wait, at least until PGY1&2 years are complete: marriage, kids. if you’re not willing to be an absentee parent (or if your spouse/kids can’t stomach it), then don’t be a resident!