Letters to the Editor  |   October 2019
Author Notes
  • Larkin Community Hospital, South Miami, Florida 
  • Arkansas Colleges of Health Education, Fort Smith 
Article Information
Medical Education / Professional Issues / Graduate Medical Education
Letters to the Editor   |   October 2019
The Journal of the American Osteopathic Association, October 2019, Vol. 119, 644a-645. doi:
The Journal of the American Osteopathic Association, October 2019, Vol. 119, 644a-645. doi:
We thank Drs Ochi and Stephan for their insightful letter regarding our article, “Resident Duty Hour Restrictions: The Implications Behind the New Data Ahead of the Single Accreditation System.”1 The elusive balance of patient safety, resident well-being, and resident education remain the cornerstones of discussions about medical trainee duty hours, especially as we approach the single-accreditation system.2 Since our article was published, the pivotal iCOMPARE (Individualized Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education) trial's patient safety data have been published,3 with findings from an analysis of 30-day mortality rates and other patient safety markers between randomized standard (restricted) vs flexible duty-hour rules for internal medicine residents. Flexible adjustment of duty-hour schedules did not adversely affect the primary outcome of 30-day mortality nor demonstrate noninferiority to readmission or death at 7 or 30 days, prolonged length of hospital stay, or patient safety indicators.3 In the end, patient safety remains top priority throughout medical training, and the iCOMPARE data for internal medicine3 training go hand-in-hand with the patient safety data for surgical trainees from the FIRST4 (Flexibility in Duty Hour Requirements for Surgical Trainees) trial—no differences were found in patient safety based on the type of duty-hour trainee regulations. 
Full data from the most robust trials comparing duty-hour regulations (FIRST4 and iCOMPARE5) suggest that trainee opinions of duty hours may vary based on the level of training and individualized institution-specific goals and objectives. These trials are the criterion standard for analysis, as there may never be more robust trials, and trainee recording of duty hours will always hinder accurate assessments. Ochi and Stephan provide unique, institution-specific strategies for mitigating duty-hour regulations and optimizing trainee well-being, and we commend their individualized, proactive efforts. We agree with the authors that a call for decreased work hours overall is needed but that the emphasis should be on effective work hours that provide individual satisfaction and gratification in one's work. We need to bring the physician back to the bedside to emphasize continued focus on patient-centered care. The Accreditation Council for Graduate Medical Education has spearheaded such investigative programs and provided funding for a growing number of innovative project campaigns.6 
We suggest that the focus be placed on individual institutions going forward to find ways to prevent both workplace and personal burnout and enhance trainee satisfaction. Today's trainees are not only graduating with increased debt,7-8 but they are graduating mentally and physically exhausted9 and, most importantly, are weighed down by tasks unrelated to patient care. Herein, we must encourage proactive development of programs and tactics for trainees to stimulate more effective ways of patient care and to minimize burnout. Graduating trainees can then carry such advancements to their clinical practices and work communities. 
Berry AC, McClain EK. Resident duty hour restrictions: the implications behind the new data ahead of the single accreditation system. J Am Osteopath Assoc. 2018;118(8):501-503. [CrossRef] [PubMed]
Buser BR, Swartwout J, Lischka T, Biszewski M. Single accreditation system for graduate medical education: transition update. J Am Osteopath Assoc. 2019;119(4):257-262. [CrossRef] [PubMed]
Silber JH, Bellini LM, Shea JA et al. Patient safety outcomes under flexible and standard resident duty-hour rules. N Engl J Med. 2019;380(10):905-914. [CrossRef] [PubMed]
Billimoria KY, Chung JW, Hedges LV et al. National cluster-randomized trial of duty-hour flexibility in surgical training. N Engl J Med. 2016;374(8):713-727. [CrossRef] [PubMed]
Desai SV, Asch DA, Bellini LM, et al. Education outcomes in a duty-hour flexibility trial in internal medicine. N Engl J Med. 2018;378(16):1494-1508. [CrossRef] [PubMed]
Back to bedside, back to meaning in medicine. Accreditation Council for Graduate Medical Education website. Accessed May 23, 2019.
Medical School Graduation Questionnaire: 2018 All Schools Summary Report. Bethesda, MD: Association of American Medical Colleges; 2018. Accessed May 31, 2019.
AACOM 2016-17 Academic Year Survey of Graduating Seniors. Bethesda, MD: American Association of Colleges of Osteopathic Medicine; 2017. Accessed May 31, 2019.
Frejerman A, Morvan Y, Krebs MO, Gorwood P, Chaumette B. Burnout in medical students before residency: a systematic review and meta-analysis. European Psychiatry. 2019;55:36-42. [CrossRef] [PubMed]