From Pages to Practice
It’s not often that a physician reads a study in NEJM in which he was a subject. As an internal medicine resident between July 2015 and June 2016, I was one of more than 6000 residents from 63 U.S. residency programs who participated in the iCOMPARE (Individualized Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education) trial. NEJM reported the educational outcomes from this landmark study in March 2018.
Duty-hour restriction has been a heated topic since the tragic death of Libby Zion in 1984 sparked a national debate about the safety of care provided by overworked residents. In 1989, the Accreditation Council for Graduate Medical Education (ACGME) instituted policies to limit resident duty to 80 hours per week. In 2011, the ACGME further refined restrictions to maximum shift lengths of 16 hours for interns and 24 hours plus an additional 4 hours for transition of care for residents. Furthermore, all residents must have 14 hours off after 24 hours of inhouse call or 8 hours off after regular duties.
The more restrictive rules quickly raised concerns that they would erode quality of training and reduce continuity of care without any benefit to patient care. Motivated by these concerns, the FIRST (Flexibility in Duty Hour Requirements for Surgical Trainees) trial randomized 117 U.S. general surgery residency programs to the standard ACGME duty hour policy noted above or a flexible policy without maximum shift lengths and minimum time off. Both groups still maintained 80-hour workweeks, 1 day off every 7 days, and were on call no more than every third night. The FIRST trial showed that compared to the standard policy, the flexible policy had a noninferior effect on 30-day postoperative death or serious complications in patients and no significant difference in resident satisfaction.
As a counterpart to the FIRST trial, the iCOMPARE research group assessed noninferiority of the two duty hour policies on patient outcomes in internal medicine residency programs. Although analysis of the effect on patient outcomes awaits the release of Medicare data for 2015 and 2016, the headline conclusion for many will be that interns in the flexible programs were more dissatisfied with the overall quality of education and their own well-being than their peers in the standard programs. In contrast, programs directors in the flexible programs were more satisfied with the educational experience.
Having recently graduated residency, I was surprised by the notable difference in resident satisfaction, especially in the context of the neutral findings from the FIRST trial. Perhaps specific specialties are better suited for certain types of schedules. Nonetheless, the discrepant views between residents and program directors indicate a gulf between the administrators of policy and those that the policy is meant to benefit. As Dr. Graham McMahon from the Accreditation Council for Continuing Medical Education concluded in an accompanying editorial, “The contribution of the iCOMPARE trial may not be the determination of whether flexible or standard duty hours are preferred, but rather whether health system and education leaders hear the sentinel plea of residents to reform our clinical learning environments to prioritize people.” Indeed, one of the other lessons to be gleaned from the trial is the challenge of being a trainee in modern medicine.
In his book, Drive, best-selling author Daniel Pink popularized the idea that the factors that increase workplace performance and satisfaction are autonomy, mastery, and purpose. At times during residency, a trainee can possess very little of all three factors. Finding purpose in the medical profession should be easy, but it can be quickly lost in the shuffle of work that can feel menial. The iCOMPARE trial showed only 12%–13% of the typical intern’s shift time is spent on direct patient care, whereas more than 60% is spent on indirect patient care (e.g., working on a computer). Although the flexible schedule gave program directors more control over accomplishing their educational goals, residents are still subject to a rigorous schedule that leaves little room for research, career exploration, family, friends, hobbies, exercise, and rest. With more than 70% of interns reporting moderate or high scores on the Maslach Burnout Inventory in the iCOMPARE trial, it’s time for administrators to take a closer look at how to improve graduate medical education for the next generation of physicians. Ultimately, our duty is foremost to our patients, and the forthcoming mortality data from the iCOMPARE trial will deliver the final verdict on the merits of flexible work hours.