title: The Interventional Arm of the Flexibility In Duty-Hour Requirements for Surgical Trainees Trial: First-Year Data Show Superior Quality In-Training Initiative Outcomes.
abstract: OBJECTIVE
  With the implementation of strict 80-hour work week in general surgery training, serious questions have been raised concerning the quality of surgical education and the ability of newly trained general surgeons to independently operate. Programs that were randomized to the interventional arm of the Flexibility In duty-hour Requirements for Surgical Trainees (FIRST) Trial were able to decrease transitions and allow for better continuity by virtue of less constraints on duty-hour rules. Using National Surgical Quality Improvement Program Quality In-Training Initiative data along with duty-hour violations compared with old rules, it was hypothesized that quality of care would be improved and outcomes would be equivalent or better than the traditional duty-hour rules. It was also hypothesized that resident perception of compliance with duty hour would not change with implementation of new regulations based on FIRST trial.
  
  
  METHODS
  Flexible work hours were implemented on July 1, 2014. National Surgical Quality Improvement Program Quality In-Training Initiative information was reviewed from July 2014 to January 2015. Patient risk factors and outcomes were compared between institutional resident cases and the national cohort for comparison. Residents' duty-hour logs and violations during this period were compared to the 6-month period before the implementation of the FIRST trial. The annual Accreditation Council for Graduate Medical Education resident survey was used to assess the residents' perception of compliance with duty hours.
  
  
  RESULTS
  With respect to the postoperative complications, the only statistically significant measures were higher prevalence of pneumonia (3.4% vs. 1.5%, p < 0.05) and lower prevalence of sepsis (0% vs. 1.5%, p < 0.05) among cases covered by residents with flexible duty hours. All other measures of postoperative surgical complications showed no difference. The total number of duty-hour violations decreased from 54 to 16. Had the institution not been part of the interventional arm of the FIRST trial, this number would have increased to 238. The residents' perception of compliance with 80-hour work week from the Accreditation Council for Graduate Medical Education survey improved from 68% to 91%.
  
  
  CONCLUSIONS
  Residents with flexible work hours on the interventional arm of the FIRST trial at our institution took care of a significantly sicker cohort of patients as compared with the national dataset with equivalent outcomes. Flexible duty-hour policy under the FIRST trial has enabled the residents to have fewer work-hour violations while improving continuity of care to the patients. Additionally, the overall perception of resident compliance with the duty-hour requirements was improved.
authors.affiliation: Department of Surgery, Mercer University School of Medicine, Memorial University Medical Center, Savannah, Georgia. Electronic address: issaswims@yahoo.com.
authors.forename: Issa
authors.initials: I
authors.lastname: Mirmehdi
authors.affiliation: Department of Surgery, Mercer University School of Medicine, Memorial University Medical Center, Savannah, Georgia.
authors.forename: Cindy-Marie
authors.initials: CM
authors.lastname: O'Neal
authors.affiliation: Department of Surgery, Mercer University School of Medicine, Memorial University Medical Center, Savannah, Georgia.
authors.forename: Davis
authors.initials: D
authors.lastname: Moon
authors.affiliation: Department of Surgery, Mercer University School of Medicine, Memorial University Medical Center, Savannah, Georgia.
authors.forename: Heather
authors.initials: H
authors.lastname: MacNew
authors.affiliation: Department of Surgery, Mercer University School of Medicine, Memorial University Medical Center, Savannah, Georgia.
authors.forename: Christopher
authors.initials: C
authors.lastname: Senkowski
mesh_terms: D000328:Adult; D002055:Burnout, Professional / Q000517:prevention & control*; D015331:Cohort Studies; D004503:Education, Medical, Graduate / Q000379:methods; D005260:Female; D013502:General Surgery / Q000379:methods*; D006801:Humans; D007396:Internship and Residency / Q000379:methods*; D008297:Male; D017063:Outcome Assessment, Health Care; D010561:Personnel Staffing and Scheduling / Q000592:standards* / Q000639:trends; D058996:Quality Improvement; D016032:Randomized Controlled Trials as Topic; D012189:Retrospective Studies; D014940:Work Schedule Tolerance; D016526:Workload
keywords: ACGME; FIRST trial; NSQIP; Patient Care; Practice-Based Learning and Improvement; Professionalism; QITI; resident’s duty hours