The effect of resident work hour regulations on orthopaedic surgical education

Accreditation Council for Graduate Medical Education (ACGME) resident work hour regulations have been effective since July 2003. Several areas affected by these changes have been identified, including surgical education. In the current study, the authors evaluated the impact of these changes on surgical education at a two-person-per-year orthopaedic training program. Operative case experiences of PGY 2 and 3 residents during the academic years 2002-2003 and 2003-2004 were compared utilizing ACGME case logs. A data entry log was also distributed to examine subjectively the effects on operative case load. ACGME data showed that PGY 2 and 3 residents performed 21.5% fewer cases between years. The average number of cases per rotation decreased by 20.44% (p =.009, paired t-test). Subjective results also showed a decrease, with an average of 10.8% of cases missed per resident. This study shows that residents who have begun training post-80-hour work week will do fewer procedures. This may result in a decreased level of skill, or it may shift operative experience to the senior resident years, prolonging the learning curve. Regardless, future analysis must be done to determine the full impact on training of the orthopaedic resident.     

Three-year results of mandated work hour restrictions: attending and resident perspectives and effects in a community hospital

In response to the Accreditation Council of Graduate Medical Education mandated resident work hour restrictions, our residency program used a night float system in 2003. We undertook a survey of attending staff and residents to assess its effects on patient care and resident education. An anonymous survey was administered to attending staff and residents 1 year and 3 years after work hour restrictions took effect. The areas of disagreement include: beneficial effect on education (residents vs faculty: in 2004, 87% vs 22%, respectively, P = 0.02; in 2006, 71% vs 22%, P = 0.03); beneficial effect on patient care (in 2004, 53% vs 10%, P = 0.03); and compromised continuity of care (in 2004, 27% vs 70%, P = 0.04; in 2006, 7% vs 89%, P = 0.0002). One area of agreement was that residents' quality of life had improved. Both disagreed that more errors were being made and that work hour restrictions should be mandated on practicing surgeons. Attending staff and residents have deeply held opinions regarding the effects of work hour restrictions. This reflects a continuing dissatisfaction with providing patient care and educating residents under a set of requirements that solely addresses resident sleepiness and fatigue.     

A template for change and response to work hour restrictions

Surgical program directors are seeking how to best meet the work hour restrictions recently mandated by the American College of Graduate Medical Education. Implementation of an 80-hour work week forces major change to graduate medical education, especially surgical education. Creative restructuring of surgical training is necessary to ensure compliance. Developing an innovative solution to meet these requirements must consider programmatic needs, requiring commitment to a change process. The Department of Surgery at Eastern Virginia Medical School experienced a 5-month strategic planning process that generated the Mendoza plan. This plan uses an every third night call model and a night float model to meet site-specific needs. The specifics of the Mendoza plan protect the cornerstone of surgical education, which is continuity of patient care and resident education. The Mendoza plan, and the process leading to its development, may provide insightful information for other surgical residency programs planning to meet work hour guidelines.     

Effects of resident duty-hours restrictions on surgical and nonsurgical teaching faculty

OBJECTIVE: To evaluate the effects of resident duty-hours restrictions on teaching faculty, patient care, and the institutional climate at a single center. METHODS: An anonymous questionnaire was provided to all teaching faculty (N = 606) at a single institution from March through October 2006. The questionnaire focused on perceptions of job satisfaction, workload changes, and effects on patient care and the institution. RESULTS: Overall response rate was 41% (n = 248). More than half of faculty (n = 140 [56%]) feel they have less time for teaching, 33% report less time for extracurricular activities, and 42% report increased work hours. Forty-three percent of respondents (n = 106) were less satisfied with their jobs after implementation of resident duty-hours restrictions, while only 2% (n = 5) were more satisfied. Of the respondent faculty, surgeons were more likely than nonsurgeons to report increased work hours (54% vs 34%; P = .002), decreased time for teaching (66% vs 51%; P = .03), lower job satisfaction (55% vs 35%; P = .003), and negative effects on their personal relationships outside of work (24% vs 12%; P = .01). Although most responses suggest that the restrictions on resident duty hours have not adversely affected patient care or the institutional climate, 33% of respondents (n = 82) felt that patient care was worse. CONCLUSIONS: Surgeons reported a particularly negative effect from resident duty-hours reform, especially within the areas of job satisfaction, time for teaching, and workload. Efforts to counteract these effects will be critical to maintain and recruit teaching faculty.     

Before and after resident work hour limitations: an objective assessment of the well-being of surgical residents

PURPOSE: To assess the impact of resident work hour limitations on how surgical residents feel about their training, patient care, and their overall well-being. METHODS: Three surveys were administered to 28 categorical surgery residents before and after implementation of the Accreditation Council on Graduate Medical Education (ACGME) work hour restrictions. The surveys consisted of a Beck Depression Inventory II (BDI-II), a SF-36 Health Status Profile (SF-36), and a custom 20-item Likert scale survey. The results of the surveys were then compiled to evaluate any significant changes in resident attitudes. RESULTS: Only minor differences were noted in the BDI-II and SF-36. The Likert scale survey showed no differences in attitude toward resident education, faculty interaction, operating room exposure, patient care, or continuity. Significant improvements were noted in the feelings of residents toward time for reading, rest, time with family, and socializing. CONCLUSIONS: Although a great deal of concern has existed about the impact of work hour limitations on surgery resident training, residents feel their training has not been affected significantly. Work hour restrictions have, however, had a positive impact on the lives of surgery residents outside of the hospital.     

Impact of mandatory resident work hour limitations on medical students' interest in surgery

BACKGROUND: The number of US medical students applying for general surgery residency has been declining. Recent studies have shown that the issue of "controllable lifestyle" has become a critical factor in medical students' decision-making process. We postulate that widespread implementation of resident work hour limitations would bolster medical students' interest in pursuing surgical careers. STUDY DESIGN: Students from New York University School of Medicine were surveyed about their attitudes toward work hour limitations and its effect on their interest in pursuing a surgical residency. One hundred thirty-two students participated. RESULTS: Nearly 95% of respondents believed that work hour limitations were a positive change and, if all other factors were equal, they would choose a training program that used work hour limitations over one that did not. The most common reasons cited in favor of limits were improvements in resident lifestyle (42%) and patient safety (34%). Fifty-three percent of respondents indicated that presence of work hour limitations alone would increase their interest in considering a surgical residency and only 2% of medical students indicated that it would lessen their interest in surgery. Not surprisingly, intellectual interest in a specialty was the most important factor in choosing a residency for 86% of students. Nevertheless, work hour limitations were designated a higher priority than future salary by 55% of medical students. CONCLUSIONS: The presence of work hour limitations has a positive impact on medical students' interest in surgery. Widespread implementation of work hour limitations may bolster the number of applications for surgical residency.     

Work-hour restrictions and orthopaedic resident education: a systematic review

Purpose

The ACGME (US) and The European Working Time Directive (UK) placed work-hour restrictions on medical trainees with the goal of improved patient safety. However, there has been concern over a potential decrease in medical education. Orthopaedic training is the focus of this study. We examined previously published subjective and objective data regarding education and work-hour restrictions and developed the questions: Do specific perceptions emerge within the subjective studies examined? Are there objective differences in educational measures before and after work-hour restrictions? Is there a difference between the subjective and objective data?

Methods

A systematic review was conducted via MedLine, regarding orthopaedic studies in the USA and UK, with reference to work-hour restrictions and education.

Results

Subjective survey studies demonstrate that residents and attending physicians have a negative response to work-hour restrictions because of the perceived impact on their overall education and operating room experience. Conversely, limited objective studies demonstrated no change in operative volume before or after implementation of restrictions.

Conclusions

This review highlights the need for more objective studies on the educational implications of work-hour restrictions. Studies to date have not demonstrated a measurable difference based on case logs or training scores. Opinion-based surveys demonstrate an overall negative perception by both residents and attending physicians, on the impact of work-hour restrictions on orthopaedic education. Current published data is limited and stronger evidence-based data are needed before definitive conclusions can be reached.

     

Attitudes of applicants for surgical residency toward work hour limitations

BACKGROUND: There is an ongoing debate regarding the merits of resident work-hour limitations. We postulated that this issue would be a factor in the decision-making process of applicants to surgical residency. METHODS: Candidates for surgical residency at a university-based program completed an anonymous survey during their visit. Data was analyzed by analysis of variance and the chi-square test. RESULTS: Most candidates viewed work-hour limitations as being favorable to their future training. Nevertheless, work-hour limitations ultimately were not a critical factor in the decision-making process compared with issues such as quality of training and program reputation. Candidates ranked "reading in surgery" the most likely way they would spend the leisure time afforded by work-hour limitations. CONCLUSIONS: Most applicants for surgical residency consider work hour-limitations as being favorable to their training and view the extra free time as an opportunity for furthering their education. However, other issues take precedence when choosing a residency.     

The changing face of trauma management and its impact on surgical resident training

BACKGROUND: The management of trauma patients has become increasingly nonoperative, especially for solid abdominal organ injuries. However, the Residency Review Committee (RRC) still requires an operative trauma experience deemed essential for graduating general surgical residents. The purpose of this study was to review the trauma volume and mix of patients at two trauma centers and determine the major operative trauma cases available to residents involved in the care of these patients. METHODS: A retrospective chart review was conducted at the two trauma centers used by the Michigan State University surgery residency. Both of the trauma centers are American College of Surgeons verified. Surgical residents are involved with the care of every trauma patient at each of the hospitals. Cumulative data were collected and analyzed from January 1, 1997, through December 31, 1999. Age, gender, mechanism of injury (blunt vs. penetrating), Injury Severity Score, length of stay, operative interventions, and patients managed nonoperatively were reviewed. RESULTS: There were 434 patients selected for this study from 2,340 patients admitted to the trauma services. Male patients accounted for 66% of patients and female patients accounted for 34% of patients. Blunt trauma was the mechanism in 89% of patients, with penetrating trauma accounting for the other 11% of patients. Of the total number of patients, motor vehicle crashes accounted for the majority of cases, 325 of 434 (75%). Overall, 85% (370 of 434) of patients were managed without an index trauma surgical procedure according to RRC guidelines. Only 14.7% (64 of 434) of patients underwent operative intervention that qualified as index trauma surgical cases identified by the RRC. The spleen and small bowel were the two most commonly injured organs found at laparotomy. Nonoperative intervention of many patients with solid abdominal organ injuries did not meet the operation requirements expected by the RRC. CONCLUSION: Our residency program had 10 graduating chief residents over the 3-year time period. With only 64 operative trauma cases, this yields an average of 6.4 trauma cases per resident. This falls significantly short of the 16-case minimum requirement in trauma surgery established by the RRC. The operative trauma requirements established by the RRC for graduating residents may be unattainable in many residency programs because of the high incidence of blunt trauma and the changing patterns of trauma management.     

Implementing resident work hour limitations: lessons from the New York State experience

OBJECTIVE: To determine the impact of work hour limitations imposed by the 405 (Bell) Regulations as perceived by general surgery residents in New York State. SUMMARY BACKGROUND DATA: New Accreditation Council for Graduate Medical Education (ACGME) requirements on resident duty hours are scheduled to undergo nationwide implementation in July 2003. State regulations stipulating similar resident work hour limitations have already been enacted in New York. METHODS: A statewide survey of residents enrolled in general surgery residencies in New York was administered. RESULTS: Most respondents reported general compliance with 405 Regulations in their residency programs, a finding corroborated by reported work hours and call schedules. Whereas a majority of residents reported improved quality of life as a result of the work hour limitations, a substantial portion reported negative impacts on surgical training and quality and continuity of patient care. Negative perceptions of the impact of duty hour restrictions were more prevalent among senior residents and residents at academic medical centers than among junior residents and residents at community hospitals. CONCLUSIONS: Implementation of resident work hour limitations in general surgery residencies may have negative consequences for patient care and resident education. As surgical residency programs develop strategies for complying with ACGME requirements, these negative consequences must be addressed.     

Maintaining outcomes in a surgical residency while complying with resident working hour regulations

BACKGROUND: Regulatory requirements for resident working hours were designed to improve patient care. Compliance challenges a training program to meet procedural and clinical requirements. This is a retrospective study of a 5-year experience in addressing the challenges and studying the impact of compliance on resident caseload and board performance. METHODS: Our surgical program adopted strict start/stop working hours for clinical contact. Program leadership modified the program to establish procedural and performance criteria. Procedures were prioritized and assignments were changed to maximize clinical and procedural experience while reducing redundancy of experience. Procedural activity was monitored frequently. Compliance with working hour regulations was monitored and behavior modified where necessary. A web based computer program was developed to improve measurement of compliance and provide feedback. Outcome measures included both the number of procedures as reported by the ACGME and performance on the American Board of Surgery, Qualifying Examination. RESULTS: Working hour compliance is greater than 95%. First time pass rate on the Qualifying examination is 90% (45/50). There is no significant difference in the procedural activity. CONCLUSION: Complying with working hour regulations improves the quality of a resident's life and can be achieved while maintaining procedural experience and guaranteeing academic development.     

Impact of resident work-hour restrictions on trauma care

BACKGROUND: In July 2003, the American Council for Graduate Medical Education (ACGME) required residency programs to significantly restrict resident work hours. The effect of these regulations on trauma services has not yet been investigated. The purpose of this study was to evaluate the effect of the ACGME regulations on the care of injured patients and resident education. METHODS: A 24-question instrument was mailed to a sample of senior trauma surgeons. RESULTS: Shift work has become significantly more common among trauma residents since July 2003 (14% vs. 53.4%, (P < .001)). Fifty-four percent of respondents believed that trauma education has worsened and 45% believed that patient care has worsened as a result of the work-hour restrictions. CONCLUSIONS: The ACGME-mandated work-hour restrictions have had a dramatic effect on resident and staff surgeons involved in the care of injured patients. Appropriate methods of responding to these challenges must be developed to improve trauma care and enhance resident education.     

The impact of the 80-hour resident workweek on surgical residents and attending surgeons

OBJECTIVE: To assess the impact of the 80-hour resident workweek restrictions on surgical residents and attending surgeons. SUMMARY BACKGROUND DATA: The ACGME mandated resident duty hour restrictions have required a major workforce restructuring. The impact of these changes needs to be critically evaluated for both the resident and attending surgeons, specifically with regards to the impact on motivation, job satisfaction, the quality of surgeon training, the quality of the surgeon's life, and the quality of patient care. METHODS: Four prospective studies were performed at a single academic surgical program with data collected both before the necessary workforce restructuring and 1 year after, including: 1) time cards to assess changes in components of daily activity; 2) Web-based surveys using validated instruments to assess burnout and motivation to work; 3) structured, taped, one-on-one interviews with an external PhD investigator; and 4) statistical analyses of objective, quantitative data. RESULTS: After the work-hour changes, surgical residents have decreased "burnout" scores, with significantly less "emotional exhaustion" (Maslach Burnout Inventory: 29.1 "high" vs. 23.1 "medium," P = 0.02). Residents have better quality of life both in and out of the hospital. They felt they got more sleep, have a lighter workload, and have increased motivation to work (Herzberg Motivation Dimensions). We found no measurable, statistically significant difference in the quality of patient care (NSQIP data). Resident training and education objectively were not statistically diminished (ACGME case logs, ABSITE scores). Attending surgeons perceived that their quality of their life inside and outside of the hospital was "somewhat worse" because of the work-hour changes, as they had anticipated. Many concerns were identified with regards to the professional development of future surgeons, including a change toward a shift-worker mentality that is not patient-focused, less continuity of care with a loss of critical information with each handoff, and a decrease in the patient/doctor relationship. CONCLUSION: Although the mandated restriction of resident duty hours has had no measurable impact on the quality of patient care and has led to improvements for the current quality of life of residents, there are many concerns with regards to the training of professional, responsible surgeons for the future.