Desai SV. N Eng J Med. 2018;doi:10.1056/NEJMoa1800965.

March 20, 2018
3 min read

Education, care time unaffected by limited work shifts for trainees


Desai SV. N Eng J Med. 2018;doi:10.1056/NEJMoa1800965.

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David A. Asch

Limited shifts and workweeks for internal medicine trainees and interns, compared with flexible models that allow first-year residents to work longer hours, do not result in any difference in time spent on education and direct patient care, according to findings published in the New England Journal of Medicine.

In addition, the researchers found that while interns in flexible programs were more likely to report dissatisfaction with their educational experience, program directors who administered flexible work schedules were more satisfied with the experience.

“As a nation, we invest in the science that creates new treatments for disease and we get great benefits from those investments, but we have made considerably less investment in the science that improves the training of the physicians who will prescribe those new treatments,” David A. Asch, MD, of the University of Pennsylvania Perelman School of Medicine, told Healio Rheumatology. “The iCOMPARE study represents a long-needed scientific approach to transforming medical education.”

Time trainees and interns spent on education and patient care were unaffected by limited shifts and workweeks, according to researchers.
Source: Shutterstock

As part of a larger, 5-year study led by the Perelman School of Medicine in collaboration with Johns Hopkins University, the “Individualized Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education” (or iCOMPARE) clinical trial is intended to assess the impact of an increased physician workload on patient care and outcomes.

iCOMPARE is funded in part by the Accreditation Council for Graduate Medical Education (ACGME), which in 2011 imposed strict limits medical trainees’ schedules, restricting interns to 16-hour shifts and more senior residents to 28-hour shifts. ACGME also limits residents to 80-hour workweeks, and mandates 1 day off for every 7 workdays.

To evaluate the effect of alternative duty hour policies on resident education, the researchers analyzed 63 internal medicine residency programs at large hospitals throughout the United States, which were randomly assigned to institute either standard duty hour policies or more flexible schedules that only required a maximum of 80-hour workweeks and 1 day off every 7 days.

Observers followed the daily routines of 80 interns, of whom 44 worked flexible schedules while 36 had their shifts limited by standard policies. In addition, the researchers analyzed the national in-training exam scores of 1,687 second-year residents. At the study’s conclusion, the researchers surveyed 1,200 interns and 62 program directors regarding their satisfaction with their respective programs. In all, 49% of interns and 98% of directors responded to the survey.

According to the researchers, there was no significant difference between the programs in mean percentages of time trainees spent on direct patient care and education, with about 12% to 13% of available time dedicated to care and 7% on education demonstrated in both groups. There was also no significant difference in the trainees’ perceptions of appropriate care-education balance. The researchers also found no difference between the two groups in terms of exam scores, with an average score of 68.9% in flexible programs and 69.4% in limited-hour programs.


The survey of interns showed that those in flexible programs were more likely to report dissatisfaction with multiple aspects of training, including educational quality (OR = 1.67; 95% CI, 1.02-2.73) and overall well-being (OR = 2.47; 95% CI, 1.67-3.65). However, program directors of flexible programs were less likely to report dissatisfaction with multiple educational processes, including time for bedside teaching (OR = 0.13; 95% CI, 0.03-0.49).

The iCOMPARE study will also eventually provide data from the 63 participating hospitals on residents’ sleep and alertness, patient mortality and other clinical outcomes, according to the press release.

“Many educators have worried that the shift work created by limited duty hours will undermine the training and socialization of young physicians,” Asch said in the release. “Educating young physicians is critically important to health care, but it isn’t the only thing that matters. We didn’t find important differences in education outcomes, but we still await results about the sleep interns receive and the safety of patients under their care.” – by Jason Laday

Disclosure: The researchers report funding from the National Heart, Lung and Blood Institute and the ACGME.