181Some have called into question the validity of the conclusions drawn by the FIRST
trial due to the possibility that surgical residents are underreporting their duty hours.
Prior to the conduct of the FIRST trial, several publications noted that falsification
of duty hours and noncompliance with ACGME duty hours are common. Drolet
et al. published the results of an informal survey in which 62% of surveyed surgical
residents falsely report their duty hours, and 67% were noncompliant with ACGME
standards [ 56 ]. For comparison, duty-hour falsification and ACGME noncompli-
ance occur in 43% and 53% of all residents that were surveyed across all specialties.
This behavior was also most prevalent in the PGY-1 year and decreased with
increasing PGY level. Other studies have noted similar findings, but perhaps this
issue can be viewed as an example of professionalism and a means to identify sys-
temic work-hour issues that need to be addressed on a programmatic level [ 57 ].
Billmoria et al. recently reported their own survey of residents who participated in
the FIRST trial and the frequency of violating the prescribed duty-hour limitations
[ 58 ]. In the month prior to the administration of this survey, the group assigned to the
standard duty-hour policy, 24% of PGY-1 residents worked more than 16 hours con-
tinuously 1–2 times, and 6% did this more than five times. In a similar manner, 25%
of PGY-2 through PGY-5 residents worked more than 28 hours continuously on 1–2
occasions, while 4% did this more than five times in the preceding month. Additionally,
approximately 20% of residents surveyed had less than 8 hours off between shifts, and
15% had less than 14 hours off after being on call 1–2 times in the preceding month.
This occurred more than five times in the preceding month in 4% and 4%, respec-
tively, of residents in the standard duty-hour group. Importantly, 33% of residents
worked more than 80 hours per week 1–2 times in the prior month and 16% exceed
80 hours per week 3–5 times in the prior month. This demonstrates that even in highly
scrutinized surgery residency programs, violations frequently occur. Clearly, the flex-
ible duty-hour arm of the FIRST trial violated ACGME duty-hour requirements by
design. Therefore, it is no surprise that the residents in this group more frequently
worked more than 16 hours (at the PGY-1 level), more than 28 hours continuously at
the PGY-2 level and above, and more often had fewer than 8 h off between shifts when
compared to the standard group. Despite these differences, there was no difference in
the percentage of residents who violated the 14-hour off after call rule. When both
groups of residents were asked about the reasons that they chose to violate their duty-
hour limits, most cited the desire to facilitate care transitions, stabilize a critically ill
patient, or operate on a patient they know well. This was certainly more frequent as
the PGY level increased. Additionally, many used the extra time to perform “routine”
tasks, complete documentation, or round with the team. The minority cited using the
extra work hours to attend educational conferences or activities.
Another long-standing argument for limitations of resident duty hours was to
allow residents time away from patient care duties to codify the information they
learn from patient care with independent and self-directed study of the medical lit-
erature. Additionally, some topics with which residents are expected to be familiar
are not commonly seen in routine practice, so can only be learned about through
diligent study. This knowledge is tested annually as surgical residents take the
American Board of Surgery In-Training Exam (ABSITE) and after completion of
9 Resident Duty Hours in Surgical Education