FIRST Trial Results Summary

Allowing surgeon trainees to work long hours does not affect safety of patients in surgery

According to a new report, allowing resident surgeons to work longer hours than currently allowed is not associated with a greater risk to patients of postoperative complications or death. The results of the study, titled Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial, involved 117 U.S. general surgery residency programs and 151 hospitals were published online in the New England Journal of Medicine.

This first-ever national randomized trial of resident duty hour policies also showed implementation of less restrictive work hour policies also showed no significant difference in residents’ satisfaction with their overall well-being and quality of their training.

Karl Bilimoria, MD, MS, FACS, lead study investigator and a Faculty Scholar at the American College of Surgeons (ACS) said:

“Making duty hour policies more flexible for surgeons-in-training appears to be safe for patients and acceptable to the trainees.”

For the study, eligible ACGME-accredited general surgery residency programs were randomly assigned to use one of two types of duty hour policies during the academic year from July 1, 2014, to June 30, 2015. Both groups adhered to three main ACGME rules – 1) The workweek was limited to 80 hours, 2) one day off in seven was required and 3) residents could not take call more often than every third night.

One group of 59 programs and their affiliated 71 hospitals participated in “Standard Policy,” with all existing ACGME duty hour policies.

The other group of 58 programs and 80 affiliated hospitals, received permission from the ACGME to waive rules on maximum shift lengths and time off between shifts. Flexible programs were given in this group – 1) interns’ work shifts could extend beyond the current maximum of 16 hours, 2) more senior residents’ hours could exceed 24, 3) residents were not required to have at least 8 hours off between shifts, and 4) they were not required to have at least 14 hours off after 24 hours of continuous duty.

Using the ACS NSQIP database, the researchers assessed a combined measure of patients’ deaths and serious complications within 30 days of a surgery. Among nearly 139,000 patients treated, the rate of this mixed result was similar in both groups – 9%. They also found no group differences for the 10 other patient outcomes studied, including the need for an unplanned second operation.

Among the 4,330 residents, 2,220 in the flexible group were not more likely to report dissatisfaction compared with the Standard Policy group consisting of 2,110 respondents.

Particularly, residents in the flexible duty hour group were far more likely to report being present for the entire duration of an operation and being able to care for their patients through an entire episode of illness, said Dr. Bilimoria.

“The results of the FIRST Trial demonstrate that greater flexibility in surgical resident work hours can prevent disruptions in patient care and surgical education, without an adverse effect on patient outcomes,” said ABS Executive Director and study coauthor Frank R. Lewis, MD, FACS.