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N Engl J Med. 2018 Apr 19;378(16):1494-1508. doi: 10.1056/NEJMoa1800965. Epub 2018 Mar 20.

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

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From the Departments of Medicine (S.V.D.), Epidemiology (A.L.S., J.T., D.M.S.), and Biostatistics (J.T.), Johns Hopkins University, Baltimore; the Departments of Medicine (D.A.A., L.M.B., K.H.C., M.L., A.M.Y., J.M.A., J.A.S.), Psychiatry (M.B., D.F.D.), and Medical Ethics and Policy (K.G.V.) and the Department of Statistics, the Wharton School (D.S.S.), University of Pennsylvania, the Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.H.C., K.G.V.), and the Department of Pediatrics, Children's Hospital of Philadelphia (O.E.-S., J.H.S.) - all in Philadelphia; the Department of Medicine, Brigham and Women's Hospital, Boston (J.T.K., D.W.B.); and the Department of Surgery and Center for Healthcare Studies, Northwestern University, Chicago (K.Y.B.).



Concern persists that inflexible duty-hour rules in medical residency programs may adversely affect the training of physicians.


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.


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). od Institute and the ACGME; iCOMPARE number, NCT02274818 .).


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 Blo

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