Use and Underlying Reasons for Duty Hour Flexibility in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial

J Am Coll Surg. 2017 Feb;224(2):118-125. doi: 10.1016/j.jamcollsurg.2016.10.046. Epub 2016 Nov 21.


Background: The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial randomly assigned surgical residency programs to either standard duty hour policies or flexible policies that eliminated caps on shift lengths and time off between shifts. Our objectives were to assess adherence to duty hour requirements in the Standard Policy arm and examine how often and why duty hour flexibility was used in the Flexible Policy arm.

Study design: A total of 3,795 residents in the FIRST trial completed a survey in January 2016 (response rate >95%) that asked how often and why they exceeded current standard duty hour limits in both study arms.

Results: Flexible Policy interns worked more than 16 hours continuously at least once in a month more frequently than Standard Policy residents (86% vs 37.8%). Flexible Policy residents worked more than 28 hours once in a month more frequently than Standard Policy residents (PGY1: 64% vs 2.9%; PGY2 to 3: 62.4% vs 41.9%; PGY4 to 5: 52.2% vs 36.6%), but this occurred most frequently only 1 to 2 times per month. Although residents reported working more than 80 hours in a week 3 or more times in the most recent month more frequently under Flexible Policy vs Standard Policy (19.9% vs 16.2%), the difference was driven by interns (30.9% vs 19.6%), and there were no significant differences in exceeding 80 hours among PGY2 to 5 residents. The most common reasons reported for extending duty hours were facilitating care transitions (76.6%), stabilizing critically ill patients (70.7%), performing routine responsibilities (67.9%), and operating on patients known to the trainee (62.0%).

Conclusions: There were differences in duty hours worked by residents in the Flexible vs Standard Policy arms of the FIRST trial, but it appeared that residents generally used the flexibility for patient care and educational opportunities selectively.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Attitude of Health Personnel*
  • Female
  • General Surgery / education*
  • General Surgery / organization & administration
  • Guideline Adherence / statistics & numerical data*
  • Humans
  • Internship and Residency / organization & administration
  • Internship and Residency / standards*
  • Internship and Residency / statistics & numerical data
  • Male
  • Personnel Staffing and Scheduling / organization & administration
  • Personnel Staffing and Scheduling / standards*
  • Personnel Staffing and Scheduling / statistics & numerical data
  • Practice Guidelines as Topic
  • United States
  • Workload / psychology
  • Workload / standards*
  • Workload / statistics & numerical data