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Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine

The educational outcomes from the iCOMPARE trial were published last week in the New England Journal of Medicine. iCOMPARE tested flexibility in duty hour policies in internal medicine residency. Sixty-three programs were randomized to 2011 rules or more flexible rules that had no limits in continuous hours of work and no mandatory minimums for time off between shifts. The primary outcomes were patient safety, sleep and alertness and education. The patient safety and sleep outcomes are not yet available.

The conclusions from the study are that interns in both arms are similar in how they spend their time and the medical knowledge they acquire (at least based on a written exam). However, there is a substantial disparity in the experience of interns (and all trainees) and their directors between the flexible and standard programs. Specifically, interns were generally more satisfied with the standard policies, while their directors were generally more satisfied with the flexible policies.

A summary of the key messages from the study are:

  • The complete interpretation of iCOMPARE can only be made after the results from Patient Safety and Sleep/Alertness are available.
  • We found little evidence the 2011 duty hours diminished the professional maturation of trainees within the ranges tested.
  • Despite the majority of interns in both arms being neutral or satisfied with their overall experience, burnout was high suggesting it is a problem beyond duty hours.
  • Satisfaction between interns and program directors was very different.
  • Program directors must engage their trainees to better understand and collaboratively address elements of the learning environment that may improve the trainee experience.

Sanjay Desai, lead author of this research and director of the Osler Medical Training Program, describes the findings as an important message for the graduate medical education (GME) community. He notes that the discrepancy in satisfaction is identifies a concerning disconnect between the key stakeholders involved. There is a need for program directors to work closely with their trainees to develop the best models to solve for collective experiences at the local level. Even more concerning, he reports, are the high levels of burnout in both arms. This is despite the fact that the majority of interns in both arms report neutral to satisfying experiences overall. These data suggest the burnout is driven by factors outside of duty hours. It is imperative that directors work with their trainees and all other stakeholders in GME to find ways to modify the learning environment to address burnout.

Click here for the Hopkins Hub article relating to the study:

ARTICLE: Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine

AUTHORS: Sanjay V. Desai, David A. Asch, Lisa M. Bellini, Krisda H. Chaiyachati, Manqing Liu, Alice L. Sternberg, James Tonascia, Alyssa M. Yeager, Jeremy M. Asch, Joel T. Katz, Mathias Basner, David W. Bates, et al., for the iCOMPARE Research Group

JOURNAL: N Engl J Med. 2018 Mar 20. doi: 10.1056/NEJMoa1800965. [Epub ahead of print]


Background Concern persists that inflexible duty-hour rules in medical residency programs may adversely affect the training of physicians. Methods We randomly assigned 63 internal medicine residency programs in the United States to be governed by standard duty-hour policies of the 2011 Accreditation Council for Graduate Medical Education (ACGME) or by more flexible policies that did not specify limits on shift length or mandatory time off between shifts. Measures of educational experience included observations of the activities of interns (first-year residents), surveys of trainees (both interns and residents) and faculty, and intern examination scores. Results There were no significant between-group differences in the mean percentages of time that interns spent in direct patient care and education nor in trainees' perceptions of an appropriate balance between clinical demands and education (primary outcome for trainee satisfaction with education; response rate, 91%) or in the assessments by program directors and faculty of whether trainees' workload exceeded their capacity (primary outcome for faculty satisfaction with education; response rate, 90%). Another survey of interns (response rate, 49%) revealed that those in flexible programs were more likely to report dissatisfaction with multiple aspects of training, including educational quality (odds ratio, 1.67; 95% confidence interval [CI], 1.02 to 2.73) and overall well-being (odds ratio, 2.47; 95% CI, 1.67 to 3.65). In contrast, directors of flexible programs were less likely to report dissatisfaction with multiple educational processes, including time for bedside teaching (response rate, 98%; odds ratio, 0.13; 95% CI, 0.03 to 0.49). Average scores (percent correct answers) on in-training examinations were 68.9% in flexible programs and 69.4% in standard programs; the difference did not meet the noninferiority margin of 2 percentage points (difference, -0.43; 95% CI, -2.38 to 1.52; P=0.06 for noninferiority). Conclusions There was no significant difference in the proportion of time that medical interns spent on direct patient care and education between programs with standard duty-hour policies and programs with more flexible policies. Interns in flexible programs were less satisfied with their educational experience than were their peers in standard programs, but program directors were more satisfied. (Funded by the National Heart, Lung, and Blood Institute and the ACGME; iCOMPARE number, NCT02274818 .).

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Link to abstract online:


Kelsey Bennett