Medical interns with flexible duty-hour policies have lower educational and personal satisfaction than interns in inflexible programs, despite there being no difference between the two programs in time spent on direct patient care and education, according to findings published in the New England Journal of Medicine.

Investigators randomly assigned internal medicine residents to either a standard duty-hour policy with fixed shift hours (n=31) or a flexible policy without limits on shift duration or time off between shifts (n=32). The investigators compared programs based on measures of educational experience in first-year residents (observations); interns, residents, and faculty (surveys); and interns only (examination scores).

No differences existed between the flexible and standard shift-hour groups with regard to the percentage of time interns spent in direct patient care and education (13.0% vs 11.8%, respectively; difference in the mixed-effects model, 1.2 percentage points; 95% CI, –0.7 to 3.1; P =.21). In addition, the investigators found no differences between groups in the subjective perception of trainees on balance between demands in the clinical space and in their education (difference, 0.02; 95% CI, −0.12 to 0.17; P =.74).

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Medical interns in the flexible program were more likely to report dissatisfaction with education (odds ratio [OR], 1.67; 95% CI, 1.02-2.73), overall well-being (OR, 2.47; 95% CI, 1.67-3.65), and the effect the program had on their personal life (OR, 6.11; 95% CI, 3.76-9.91) than interns in the standard program. Conversely, flexible programs were associated with less dissatisfaction regarding the number of admissions that could be completed (OR, 0.48; 95% CI, 0.27-0.85) and the perceived negative impact of duty-hour rules on the continuity of care (OR, 0.35; 95% CI, 0.22-0.57). Overall, both groups reported high levels of burnout as assessed by the Maslach Burnout Inventory subscale for emotional exhaustion (79% [flexible programs] vs 72% [standard programs]; OR in mixed-effects logistic-regression model, 1.43; 95% CI, 0.96-2.13).

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Considering only 45% of programs responded to the survey, the findings may not be an accurate representation of all medical trainees in the United States.

The findings indicate that medical trainees in flexible programs perceive a greater burden of the program on their personal lives, suggesting educational program directors may “need to better understand their dissatisfaction and develop mechanisms to address these effects.”


Desai SV, Asch DA, Bellini LM, et al; for the iCOMPARE Research Group. Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine [published online March 20, 2018]. N Engl J Med. doi:10.1056/NEJMoa1800965.