Adherence to study-group policy during the FIRST trial was determined by surveying program directors. This does not reflect resident-level adherence. The trial collected no data regarding actual duty-hours logged by residents or adherence to the 80-hour workweek.
All surgical residents know that practice—the care of patients—sometimes trumps policy. In practice, our responsibility to our ill patients and their families is at times more important than adhering to policy. Furthermore, we know that residency is our only chance to learn how to provide safe and effective surgical care; after residency, we may not have the same educational resources. Residents are not motivated by policy. We are motivated by practice.
Policies differed between those in the flexible versus the standard-policy arms of the trial, but I suspect that the practice of individual residents and adherence to policy may not have differed significantly between these two arms.
While probably not a real-world consideration, what if resident-level adherence to policy had objectively been evaluated during the trial? How might these data shed light on the practice implications conferred by policy changes?