Resident Schedule Utopia - The Search Continues

Written by Nicole McCoin

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Internal Medicine residents exposed to standard duty-hour policies or flexible duty-hour (FDH) policies* had no difference in the proportion of time spent in direct patient care and education and no difference on in-training exam scores. Those with FDH policies were less satisfied with educational quality and overall well-being, while program directors with FDH policies were more satisfied with multiple aspects of the educational process.

Why does this matter?
Burnout among residents is as high as 50%. This should be a call-to-action for program directors to better understand which types of schedules are the greatest drivers of dissatisfaction for trainees.

It’s all in the details...
This article left some unanswered questions. I spent a lot of time trying to pick it apart because, like any good program director, I want my residents to get the most out of their training but still maintain a good quality-of-life. Here was my bottom line with this article.

Educational endpoints, such as proportion of time spent on patient care, education, and in-training exam scores were not affected by either of these duty-hour policies. However, interns/residents seemed less satisfied from a quality-of-life perspective with the FDH structure. At first glance, that led me to think that lumping work together in long stretches without much time in between was the driver of the trainees’ dissatisfaction, and that may have been true.  However, mean length of observed shifts was 11.2 hours in both flexible and standard programs. The maximum length of shifts was different at 27.8 hours for flexible and 14.5 hours for standard duty-hour programs, yet only 4.2% of the shifts in the FDH programs lasted longer than 24 hours.  It makes sense that long shifts with little time off between may lead to lower trainee satisfaction, but we don't know from this paper how shifts were structured in the FDH programs.  By the end of the paper, I had even more questions about what schedule features made the difference. Is there a way to make both program directors and trainees happy? How do we design a schedule that strikes the perfect balance for both training and quality-of-life?  For now, I will be cognizant of lumping hours together and watching the amount of time between shifts as we search for schedule utopia.

*There are many ways you could craft a schedule using FDH policies.  In this study, the FDH did not affect the maximum number of hours in the work week or frequency of shifts, call, or days off.  They addressed the number of hours worked in a row and time off between shifts and call days.

Source
Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine.  N Engl J Med. 2018 Apr 19;378(16):1494-1508. doi: 10.1056/NEJMoa1800965. Epub 2018 Mar 20.
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Reviewed by Clay Smith and Thomas Davis

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