Evaluation of Reasons Why Surgical Residents Exceeded 2011 Duty Hour Requirements When Offered Flexibility: A FIRST Trial Analysis

On July 1, 2017, the Accreditation Council for Graduate Medical Education instituted duty hour requirement flexibility by waiving the limits on daily shift lengths while maintaining the 80-hour-per-week cap.¹ Of importance, residents can stay only after a 24-hour call if it is their choice to stay longer. Our objectives were to understand how often and why residents in the flexible arm of the Flexibility in Duty Hour Requirement for Surgical Trainees (FIRST) trial (ClinicalTrials.gov identifier NCT02050789) were exceeding duty hour requirements and to determine whether their decision to stay longer was voluntary or attributable to coercion by attending surgeons or senior residents.

The initial trial protocol was reviewed by the Northwestern University institutional review board, which determined the study to be nonhuman subjects research. All clinical general surgery residents taking the 2017 American Board of Surgery In-Training Examination were surveyed.² This analysis included only the residents in the flexible arm of the FIRST trial,³ which was a group that was working according to the new 2017 duty hour policy revision that allows staying longer for the care of a single patient. If the residents indicated that their duty hours exceeded the 2011 requirements in a typical month, they were asked additional questions about duty hour expectations and coercion (Table 1). The reasons for working longer than the required shift length were investigated and included a spectrum from voluntarily staying longer to being coerced to stay longer. We developed logistic regression models to identify (1) resident and program factors associated with exceeding the 2011 duty hour requirements and (2) factors associated with coercion to stay longer.

Overall, 1838 (99.2%) (1100 [59.8%] men and 738 [40.2%] women) of all 1852 general surgery residents in the flexible arm of the FIRST trial responded to the survey. Of the 1258 residents (68.4%) who exceeded the 2011 duty hour requirements, 273 (21.7%) indicated that their programs expected them to stay longer, as allowed in the flexible arm. A total of 334 residents (26.6%) responded that their attending surgeons expected them to stay longer, and 265 residents (21.1%) responded that their senior residents (postgraduate year [PGY] 4 and 5) expected them to stay longer. Nine hundred eighty-three residents (78.1%) responded that they voluntarily stayed longer, whereas 93 (7.4%) reported coercion from attending surgeons and 117 (9.3%) reported coercion from senior residents (Table 1). Female residents (odds ratio [OR], 1.89; 95% CI, 1.52-2.34) and junior residents (PGY 2: OR, 4.47; 95% CI, 3.32-6.03; PGY 3: OR, 1.43; 95% CI, 1.14-1.81) were more likely to report exceeding the duty hour requirements. However, no significant resident or program characteristics were associated with coercion by attending surgeons and senior residents to exceed the duty hour requirements (Table 2).

This analysis examined the possibility that coercion was a factor in exceeding duty hour limits. We found that 78.1% of residents stayed longer voluntarily, whereas only 7.4% reported feeling coerced to work past duty hour limits.

Our study has some limitations. First, the survey data were self-reported and may have included some element of recall bias; however, the survey questions were framed to reflect only the most recent 6 months of training. Second, response bias to some survey questions is possible. However, the survey was anonymous and residents seemed to have answered honestly on this survey previously³ (ie, reported both positive and negative impact of flexible duty hours).

When duty hour flexibility was used in the flexible arm of the FIRST trial, it was generally attributable to the residents choosing to stay voluntarily; however, some coercion by attending surgeons and senior residents was reported. As duty hour requirements move into an era of flexibility, programs should ensure that residents are staying for clinical and educational purposes of their own accord and are not being coerced to exceed duty hour requirements.

Corresponding Author: Karl Y. Bilimoria, MD, MS, Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, 633 N St Clair St, 20th Floor, Chicago, IL 60611 (k-bilimoria@northwestern.edu).

Accepted for Publication: March 15, 2018

Published Online: June 13, 2018. doi:10.1001/jamasurg.2018.1047

Author Contributions: Drs Blay and Bilimoria had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Blay, Yang, Bilimoria.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Blay, Hewitt, Bilimoria.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Blay, Engelhardt, Hewitt, Bilimoria.

Obtained funding: Bilimoria.

Administrative, technical, or material support: Dahlke.

Study supervision: Yang, Bilimoria.

Conflict of Interest Disclosures: None reported.

Funding/Support: This analysis was supported in part by grants 5T32HL094293 (Dr Blay) and 5T32HS000078-19 (Dr Hewitt) from the National Institutes of Health and the Thomas R. Russell, MD, FACS, Faculty Research Fellowship from the American College of Surgeons (Dr Yang). The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial was funded by the American Board of Surgery, the American College of Surgeons, and the Accreditation Council for Graduate Medical Education.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.