This landmark trial, I believe,
will ultimately take well-intentioned policies with
and transform them into best
practices for surgical training.
by David B. Hoyt, MD, FACS
Resident work hour limits have been the source of considerable consternation in the surgical community since they were intro- duced by the Accreditation Council for Graduate Medical Education (ACGME) in 2003. The ACGME revised the guidelines in 2011,
making them more restrictive. This action added to the growing concerns that members of the American College of Surgeons (ACS) and
the leaders of the American Board of Surgery (ABS) have expressed
about the effects of the rules on surgical training.
To help address these issues, leaders from the ACS and the ABS
approached the ACGME about the possibility of working together to
study the effects of adding some flexibility to the current duty hour
requirements. After months of discussion, the groups agreed to conduct the Flexibility in Duty Hour Requirements for Surgical Trainees
The results of the FIRST Trial were published in the New England
Journal of Medicine in February and show that granting training programs the latitude to allow trainees to work longer shifts or take less
time off between shifts is not associated with greater risk of patient
morbidity or mortality. This landmark trial, I believe, will ultimately
take well-intentioned policies with unintended consequences and transform them into best practices for surgical training.
The ACGME first issued the resident work hour restrictions in
response to growing public concerns that overworked, fatigued residents were more prone to medical error. The 2003 ACGME guidelines limited resident duty hours to 80 per week, mandated that residents be provided with one day per week free from all educational
and clinical responsibilities, capped continuous on-site duty at 24 consecutive hours, and required that residents have an 8-hour rest period
between all daily duty periods and after in-house call. Although many
members of the surgical community expressed trepidation that these
restrictions would negatively affect continuity of care and surgical
training, most residency programs adapted.
In 2011, the ACGME issued additional measures, which, among
other provisions, shortened the shift length for interns to a maximum
of 16 hours and to 24 hours for residents in their second year or more
of training. The new guidelines also increased resident time off from
work to 14 hours after a 24-hour in-house shift.
Residents and surgical educators have voiced concern that these
additional restrictions have led to an increase in patient handoffs,
thereby disrupting continuity of care and creating new opportunities for medical error. Moreover, many members of the surgical