Reduction of Surgical Resident Duty Hours Resulted In No Change In Outcomes

Ravi Rajaram MD Division of Research and Optimal Patient Care, American College of Surgeons Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies in the Institute for Public Health and Medicine Feinberg School of Medicine, Northwestern University, Chicago, IllinoisMedicalResearch.com Interview with:
Ravi Rajaram MD

Division of Research and Optimal Patient Care, American College of Surgeons Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies in the Institute for Public Health and Medicine
Feinberg School of Medicine, Northwestern University, Chicago, Illinois

Medical Research: What is the background for this study? What are the main findings?

Dr. Rajaram: The Accreditation Council for Graduate Medication Education (ACGME) first implemented restrictions to resident duty hours in 2003. In surgical populations, these reforms have not been associated with a change in patient outcomes.

However, in 2011, the ACGME further restricted resident duty hours to include: a maximum of 16 hours of continuous duty for first-year residents (interns), direct supervision of interns at all times, a maximum of 4 hours for transitions in care activities for residents in-house for 24 hours, and that these residents be given 14 hours off prior to returning to work. The association between the 2011 ACGME resident duty hour reform with surgical patient outcomes and resident education has not previously been reported.

The 2011 resident duty hour reform was not associated with a change in death or serious morbidity in the two years after the reform was implemented. Additionally, the 2011 duty hour reform was not associated with a change in any of the secondary outcomes examined, including any morbidity, failure to rescue, surgical site infection, and sepsis.

Furthermore, common measures of surgical resident education, such as in-training examination scores and board certification pass rates, were unchanged after the implementation of the 2011 duty hour reform when compared to scores prior to the reform.

Medical Research: What should clinicians and patients take away from your report?

Dr. Rajaram: The 2011 ACGME duty hour reform was not associated with a change in surgical patient outcomes or surgical resident education. While a reduction in duty hours may have face validity for improving patient care, other effects of these policies, including reductions in continuity of care, decreased preparedness to enter practice, and diminishment of professionalism and patient ownership, should be considered.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Rajaram: While large observational studies such as ours may help to inform this topic, additional high-level evidence in the form of randomized trials is needed. The Flexibility In duty hour Requirements for Surgical Trainees (FIRST) Trial (http://www.thefirsttrial.org/) is a currently ongoing pragmatic cluster-randomized trial in which surgical residency programs were randomized to either current duty hour requirements or flexible duty hours. Surgical patient outcomes, operative case log data, and resident survey information will be collected to assess the effect of flexible duty hour schedules on these different endpoints.

Citation:

Rajaram R, Chung JW, Jones AT, et al. Association of the 2011 ACGME Resident Duty Hour Reform With General Surgery Patient Outcomes and With Resident Examination Performance. JAMA. 2014;312(22):2374-2384. doi:10.1001/jama.2014.15277.

 

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