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A Look at Flexible vs. Standard Duty Hours in the iCOMPARE Study

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Physician duty hours have always been a concern in medical training. Burnout has become a hot topic and many suspect that burdensome duty hours may contribute to burnout while adding minimal to physician education. Others suggest that duty hour cuts affect patient care negatively by increasing hand-off and sign-outs between different providers. To investigate these concerns among others, researchers launched a first of its kind trial to compare restrictive duty hour policies for residents against a more flexible policy. It was called the Comparativeness Effectiveness of Models Optimizing Patient Safety and Resident Education study (better known as the iCOMPARE study).

The flexible policy effectively removed daily hour caps (16 hours for interns and 24+4 hours for upper-level residents per ACGME recommendations) from all internal medicine trainees, including first-year interns. The flexible policy also implemented a maximum of 80 hours per week, while mandating an average of one day off in seven over a four week period and a maximum of in-house call every 3 days. The study launched on July 1, 2015 with 63 participating internal medicine residency programs across the country. The programs enrolled were required to stick to their randomized flexible or current duty hour assignment for the entire study year.

As luck would have it, I was beginning my third year of internal medicine residency when the study kicked off, and my program was randomized to the flexible hour arm. It was implemented in the ICU rotation at our county hospital. This meant that on one of the hardest rotations of my entire residency training experience, every four days, my interns and I spent 30 continuous hours covering the medical ICU. I wrote about this physically, emotionally, and mentally exhausting experience and have been waiting for the results of the iCOMPARE study ever since.

My main concerns were always that the balance between patient safety and physician well-being likely would not be achieved by making duty hours more flexible. Prior studies have noted decreased physician cognitive function on night shifts, with some studies specifically looking at the detrimental effects of acute sleep deprivation. I always felt that flexible duty hours would not solve these issues and if anything, may just make this issue worse, even if they minimized handoffs in an attempt to improve patient safety.

Well, some of the results of the iCOMPARE study were finally published in the New England of Medicine. Titled “Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine,” this published study reports the educational experiences of studied trainees and the perceptions of the involved program directors and associated faculty.

The iCOMPARE’s hypotheses involving education were specifically:

  • Interns with flexibly duty hours would get more-direct patient care and education time.
  • Trainees and faculty with flexible duty hours would have greater satisfaction with the educational experience.
  • Interns with flexible duty hours would have comparable standardized test scores compared to those with standard capped duty hours.

The above hypotheses were studied by observing intern activity at six programs: three programs with flexible duty hours and three programs with standard duty hours. They were also studied by surveying involved trainees and faculty and by comparing trainee internal medicine in-training examination scores.

The results of the observations showed no significant difference in direct patient care and education time between the flexible versus standard duty hour programs. Survey data showed that interns in the flexible duty hour programs were less satisfied than the interns in the standard duty hour programs, but program directors were more satisfied with the flexible duty hour programs. Medical knowledge was comparable in both groups based on average in-training examination scores. And, last but certainly not least, trainees reported equally-high levels of burnout across the Maslach Burnout Inventory subscales of emotional exhaustion, depersonalization, and personal accomplishment in both groups.

The study’s findings were limited by a low 45% survey response rate and by the trainee observations only occurring at six of the 63 participating programs. Despite these limitations, many of those reading this study’s results are pleased with the fact that there were no obvious differences in the quality of education between either group. Some seem to perceive the similarities in education between the flexible and standard duty hour groups as an indication that duty hour caps may not be needed.

But, what these physicians are neglecting to notice is the fact that missing duty hour caps resulted in decreased trainee satisfaction and increased burden on their personal lives. These negatives alone suggest to me that we should definitely keep the caps in place while pursuing alternate ways to address the physician burnout that was noted in both the standard and flexible duty hour groups.

Unfortunately, this study does not capture patient safety or trainee sleep outcomes, as these are not yet available. These remain my most burning concerns about this study, so I guess I’ll just have to wait a little longer to see if I can say “I told you so.”

Farah Naz Khan is a doctor and a writer. She is a 2018 Doximity Scholar. Find her on Twitter @farah287 or via her website,

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