17 3In December of 2008, the Institute of Medicine (IOM) released a publication
entitled “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety” [ 42 ].
This body was asked by Congress to evaluate the most recent evidence on the topic
of resident work hours and provide recommendations for schedules and patient
handoffs. The IOM cited the ACGME duty-hour changes from 2003 but felt that
current evidence that work-hour limits outlined in that recommendation were not
restrictive enough. Additionally, they highlighted the need for better resident super-
vision, appropriate workloads for residents, and accurate handoffs of patients. They
also recognized that different specialties have different types of patient complexities
and degree of intervention required, which would suggest that a “one size fits all”
approach to duty hours is inappropriate. Based on their findings and those of
Landrigan (noted previously) and Czeisler et al., the IOM recommended changes to
resident duty hours as noted in Table 9.1 [ 8 , 43 ]. The surgical community was not
particularly pleased with further reductions in duty hours [ 44 ]. The ACGME
reviewed the IOM report and published its own revision to the duty-hour standards
entitled, “The ACGME 2011 Duty Hour Standard - Enhancing Quality of Care,
Supervision and Resident Professional Development” [ 45 ]. Fundamentally, this
increased the intensity for resident supervision and curtailed work hours for interns
to 16 hours of continuous duty per shift.
Recent Developments in Duty-Hour Reforms
Out of concerns that further restrictions in resident duty hours may have serious
consequences for the breadth and depth of surgical resident training, the question
was asked whether we had been too conservative with our duty-hour restrictions and
if we could safely increase the hours worked by residents in a thoughtful manner
without a compromise in patient outcomes. With duty-hour changes now the “law
of the land,” no sweeping changes were likely to be made to reverse these changes
without carefully performed studies that occurred prospectively. To design a study
without reproach, it was now necessary to petition the ACGME to waive specific
duty-hour requirements for a large group of residents in order to randomize them to
the standard duty-hour arm (the current ACGME restrictions) or a more flexible
arm. Two separate studies were proposed, one to examine this question in general
surgery residents and in internal medicine residents. The Flexibility in Duty Hour
Requirement for Surgical Trainees (FIRST) trail was designed by relevant stake-
holders in surgical resident education [ 46 , 47 ].
One hundred and seventeen general surgery programs were randomly assigned
to the current ACGME duty-hour policy group (59 programs; the standard-policy
group) or the more flexible policies (58 programs; the flexible-policy group). The
data obtained on patient-level outcomes came from reporting to the American
College of Surgeons National Quality Improvement Program (ACS NSQIP) by hos-
pitals affiliated with the surgical training programs that participated. The NSQIP
program has been well described elsewhere and includes data abstracted from the
patient medical record by trained abstractors; in this case they were not informed to
9 Resident Duty Hours in Surgical Education