182
their final year as they take the American Board of Surgery (ABS) Qualifying Exam
(written) and Certifying Exam (oral). In the flexible policy arm, there might be the
unintended consequence that the increased time in the care of patients might result
in poorer performance on these exams. Although only 2 years of residents and exam
data were available, Blay et al. studied exam results in the FIRST trial participants
[ 59 ]. When comparing the flexible-policy group to the standard-policy group, there
were no significant differences in ABSITE score. This finding was consistent over
all PGY levels. Additionally, there was no statistical difference in first time pass
rates of the ABS Qualifying Exam (Flexible: 90.4% and Standard: 90.5%) or the
ABS Certifying Exam (Flexible: 86.3% and Standard: 88.6%). This did not change
even when adjusted for the characteristics of the program. This data is limited in that
only 2 years of testing is available for review and differences may arise with a larger
cohort. Interestingly, the pass rate for the ABS Qualifying Exam over the past
5 years has been fairly steady at 80% [ 60 ]. Clearly, the FIRST trial participants are
performing well on the Qualifying Exam suggesting they may not have been as
impacted by the increase in hours worked which may not be generalizable to all
surgical trainees. A similar observation may be made about the recent results from
the last 5 years of the Certifying Exam, which have seen pass rates fluctuate between
72% and 80%.
What has been made clear from the FIRST trial is that allowing some flexibility
in the duty hours and providing fewer restrictions for residents do not seem to cause
harm to patients and provide more satisfaction to surgical residents. This paradigm
shift has now been incorporated into recent changes by the ACGME in resident duty
hours. As on July 1, 2017, PGY-1 residents will start to have more flexibility in duty
hours by allowing them to work 24-hour shifts with an extra 4 h for documentation
or education, as opposed to the 16 hour of continuous duty previously allowed [ 61 ].
The aim is that this will allow for fewer handoffs and allow for increased educational
time for PGY-1 trainees. Also, it will allow more time for PGY-1 resident to accli-
mate to the resident physician lifestyle and feel more engaged in the care of patients.
Additionally, it will certainly ease the now difficult transition between the PGY-1
year and the PGY-2 year. The other limitations on resident duty hours will remain in
place (e.g., no more than 80 hours per week averaged over 4 weeks, 8 hours off
between shifts, etc.). Importantly, the language of the Common Program Requirements
gives resident autonomy and voluntariness to be flexible in how they apply these duty
hours in the best interest of caring for patients. Such examples include “to provide
care to a single severely ill or unstable patient,” “humanistic attention to the needs of
a patient of family,” or “to attend unique educational events.”
As we move forward in the evaluation of the research that has been done in
recent years on duty hours and the correlation between needing to provide adequate
surgical education and not compromising patient care, it is important that we con-
tinue to analyze more long-term data shrewdly. Pendulum shifts will inevitably con-
tinue as there have been in the past in the amount of hours worked by residents, with
the goal to provide adequate surgical education without compromising patient care
or the well-being of the resident population. Some have pleaded that broad- sweeping
changes not be made based solely on this data as it stands to avoid shifts that could
D.J. Rea and M. Smith