Results of Randomized trial on duty hour restrictions published in NEJM

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http://www.nejm.org/doi/full/10.1056/NEJMoa1515724?query=featured_home
Doesn't appear to be paywalled.

In general, they found no statistical difference for patient outcomes, nor for resident health. There were 3X as many negative reports for those with the more "flexible" schedules on personal activities such as family/rest/etc, but apparently those don't reach significance on further statistical analysis that takes into account multiple comparison issues. They also reported better perceptions for the "flexible" group on aspects of patient care. These all rolled up to be no difference when aggregated into larger groups.

The study could be read both ways depending on your bias I believe. Either you could claim that flexibility doesn't seem to be causing any harm, so why not let programs have more flexibility where it is warranted OR you could claim that there is no difference to having all these extra handoffs, so why not go with a more stringent regime with a shorter duty hour length?

The thing that is not studied is long term educational value for the resident. Don't know that we can ever get that answer.



Here is the abstract for those who don't want to click.
BACKGROUND
Concerns persist regarding the effect of current surgical resident duty-hour policies on patient outcomes, resident education, and resident well-being.

METHODS
We conducted a national, cluster-randomized, pragmatic, noninferiority trial involving 117 general surgery residency programs in the United States (2014–2015 academic year). Programs were randomly assigned to current Accreditation Council for Graduate Medical Education (ACGME) duty-hour policies (standard-policy group) or more flexible policies that waived rules on maximum shift lengths and time off between shifts (flexible-policy group). Outcomes included the 30-day rate of postoperative death or serious complications (primary outcome), other postoperative complications, and resident perceptions and satisfaction regarding their well-being, education, and patient care.

RESULTS
In an analysis of data from 138,691 patients, flexible, less-restrictive duty-hour policies were not associated with an increased rate of death or serious complications (9.1% in the flexible-policy group and 9.0% in the standard-policy group, P=0.92; unadjusted odds ratio for the flexible-policy group, 0.96; 92% confidence interval, 0.87 to 1.06; P=0.44; noninferiority criteria satisfied) or of any secondary postoperative outcomes studied. Among 4330 residents, those in programs assigned to flexible policies did not report significantly greater dissatisfaction with overall education quality (11.0% in the flexible-policy group and 10.7% in the standard-policy group, P=0.86) or well-being (14.9% and 12.0%, respectively; P=0.10). Residents under flexible policies were less likely than those under standard policies to perceive negative effects of duty-hour policies on multiple aspects of patient safety, continuity of care, professionalism, and resident education but were more likely to perceive negative effects on personal activities. There were no significant differences between study groups in resident-reported perception of the effect of fatigue on personal or patient safety. Residents in the flexible-policy group were less likely than those in the standard-policy group to report leaving during an operation (7.0% vs. 13.2%, P<0.001) or handing off active patient issues (32.0% vs. 46.3%, P<0.001).

CONCLUSIONS
As compared with standard duty-hour policies, flexible, less-restrictive duty-hour policies for surgical residents were associated with noninferior patient outcomes and no significant difference in residents’ satisfaction with overall well-being and education quality. (FIRST ClinicalTrials.gov number, NCT02050789.)

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great thing about a noninferiority trial is that some, such as the American College of Surgeons, will spin it one way (more flexible duty hour policy results in no difference in patient safety but better continuity of care and better training), while others will spin it another way (limiting hours worked does not harm patient safety and lets residents be better rested, have time for research, be able to prepare/read for cases, see loved ones)
 
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great thing about a noninferiority trial is that some, such as the American College of Surgeons, will spin it one way (more flexible duty hour policy results in no difference in patient safety but better continuity of care and better training), while others will spin it another way (limiting hours worked does not harm patient safety and lets residents be better rested, have time for research, be able to prepare/read for cases, see loved ones)

Except that with the current restrictions and night float requirements, you actually usually get less time off. When I was a fellow, we had a pool of two interns that would work on the weekends. Before the rules, they would have one on Saturday and one on Sunday. After the rules they would have one work a half day on Saturday and Sunday and the other work a half night on each day. They still had to get their day off, but the one who worked the night portion got from 7 am on Monday to 7 am on Tuesday as his day off. That blew.
 
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Part of the ACGME hours requirements include that the day off can't regularly be scheduled on a post call day. I think once a month or something you could get away with it.
 
I think the #1 thing to take home from this study is that no matter how you package it, surgery residents just hate their life.
 
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I think the #1 thing to take home from this study is that no matter how you package it, surgery residents just hate their life.

It's less than 15% that feel dissatisfied with their well-being.
 
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Except those p values are atrocious and in one case the confidence interval actually goes above 1 which basically means the data is garbage.

I'll stand by my statement as it is based on years of solid observation of calling surgery residents to do my bidding.
 
Anyone is miserable when the ED calls. Except this one hospitalist I know who is always happy for some reason.
 
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