E. Blay1, K. E. Engelhardt1, B. Hewitt1, C. Quinn1, A. R. Dahlke1, A. D. Yang1, K. Y. Bilimoria1 1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA
Introduction: As of July 1, 2017, the Accreditation Council for Graduate Medical Education (ACGME) has instituted duty hour limit flexibility by waiving caps on daily shift lengths, while maintaining the 80-hour-per-week cap. Importantly, residents can only stay 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 FIRST Trial were working longer than standard duty hour limits and whether this was due to coercion by attendings and senior residents or a voluntary decision made by the individual resident to stay longer.
Methods: All clinical General Surgery residents taking the 2017 American Board of Surgery In-Training Examination (ABSITE) were surveyed. This analysis was limited to residents in the Flexible Arm of the FIRST Trial. The main outcome was number of times the resident exceeded 2011 duty hour limits in a typical month dichotomized into 0 or ≥ 1 event. If residents indicated that their duty hours exceeded limits in a typical month, they were asked additional questions about duty hour expectations and coercion on a 5-point Likert scale from “Strongly Agree” to “Strongly Disagree.” Rates were compared and regression models were developed to (1) identify resident and program factors associated with exceeding standard duty hour limits and (2) identify predictors of coercion to stay longer.
Results: In the Flexible Arm of the FIRST trial, 1838/1838 (100%) of clinical residents in 58 programs responded to the survey. Of 68% (n=1258) residents who exceeded duty hour rules, 22% (n= 273) of residents said their programs expected them to stay longer than standard duty hour limits. When residents stayed longer than standard duty hour limits, 78% (n= 983) responded that they voluntarily stayed longer, while 7% (n=93) reported coercion from attendings and 9% (n=117) reported coercion from senior residents. Although females (OR 1.89, 95% CI [1.52-2.34]), interns (OR 4.47, 95% CI [3.32-6.03]) and junior residents (OR 1.43, 95% CI [1.14-1.81]) were more likely to report exceeding standard duty hour limits, there were no significant resident or program characteristics associated with coercion by attendings or senior residents to exceed duty hour limits.
Conclusion: When duty hour flexibility was utilized in the Flexible Arm of the FIRST Trial, it was generally due to the residents choosing to stay voluntarily; however, there was some coercion by attendings and senior residents. As duty hour rules transition into an era of flexibility, programs should be cognizant of ensuring residents are staying for clinical and educational purposes of their own accord and are not being coerced to break ACGME duty hour regulations unnecessarily.