Impact of the 80-hour work week on resident emergency operative experience

BACKGROUND: The goal of this study was to analyze the impact of the 80-hour work week on the emergency operative experience of surgical residents. METHODS: A 2-year retrospective comparison of the operative experience in emergency abdominal procedures of postgraduate year 4 and 5 residents in a city hospital before (group 1) and after (group 2) duty hour restriction. RESULTS: There was no difference between groups in the mean number of procedures performed as the primary surgeon, but group 2 showed a 40% decrease in technically advanced procedures with a 44% increase in basic procedures. The study also demonstrated a 54% decrease in the operative volume as first assistant. Operative continuity of care by residents decreased from 60% to 26% of cases. CONCLUSIONS: The ACGME regulatory environment is adversely affecting the emergency operative experience of surgical residents. Our findings underscore the need to develop alternative methods to augment the residents' operative experience.     

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.     

Effect of the 80-hour work week on resident operative experience in general surgery

BACKGROUND: The goal of this study was to determine the effect of the 80-hour work week on resident operative experience. METHODS: General surgery resident operative experience was evaluated during a 4-year period and divided into 2 groups: before (group A [July 1, 2001, to June 30, 2003]) and after (group B July 1, 2003, to June 30, 2005]) implementation of the Accreditation Council for Graduate Medical Education duty hour guidelines. RESULTS: There was a significant decrease in mean total and primary surgeon cases in group B for postgraduate year (PGY) levels 1, 2, and 4 (P < or = .001). There was a significant decrease in PGY 5 teaching assistant and PGY 1 first assistant experience in group B (P < or = .001). There was no difference in PGY 3 resident operative volume. CONCLUSIONS: The mandated work-hour guidelines have negatively impacted the operative experience of general surgery residents, especially at the junior level. Despite implementing modifications designed to optimize resident operative experience, surgical training programs may require further adaptations.     

24 hours on-call and acute fatigue no longer worsen resident mood under the 80-hour work week regulations

PURPOSE: Studies in on-call residents have shown that mood is worsened by fatigue as indicated by increased scores on measures of depression, anxiety, confusion, and anger using the Profile of Mood States (POMS). In prior sleep deprivation studies, mood has been shown to be more affected than either cognitive or motor performances. The purpose of this study was to examine the effect of the 80-hour work week regulations on resident mood in general and in a post-call period (PC). METHODS: Institutional Review Board approval was obtained to survey the residents and publish the results. POMS is a 65-item adjective questionnaire that includes subscales for measuring tension-anxiety, anger-hostility, depression-dejection, vigor-activity, fatigue-inertia, and confusion-bewilderment, with the summation of the scales forming a total mood disturbance score. Surgical residents were tested at a 9 am didactic curriculum session (9 am has been shown to correlate with the nadir of performance). Residents were tested after nights off call (NOC) or after PC. Time asleep in the preceding 24 hours and other demographic data were also collected. Acute fatigue (AF) was defined as <4 hours sleep. The two-sample t-test and linear regression were used to assess differences between groups. RESULTS: A total of 123 standardized POMS mood questionnaires were administered on 4 occasions to 51 surgical residents, 35 men and 16 women at levels PGY-1 through PGY-5. Overall, 33 tests (27%) were taken after PC and 90 (73%) were taken after NOC. Acute fatigue residents had a mean sleep time of 2.2 (+/-1.5) hours, whereas rested (R) residents had a mean sleep time of 6.7 (+/-2.2) hours (whether PC or NOC). No statistical differences in mean values of vigor, anger, depression, concentration, fatigue, tension, or total score were observed between PC and NOC or between AF and R residents. There was no significant relationship between acute sleep deprivation and total mood disturbance, whether PC or NOC. In linear relationships, NOC total score and hours slept had r2 = 0.01 (p = 0.44), whereas PC total score and hours slept had r2 = 0.07 (p = 0.14). CONCLUSION: Although POMS was given 4 times, only 27% were PC, which reflects our 1 in 4 night in-house coverage. In contrast to earlier studies, resident mood, as measured by POMS, is no longer related to PC/NOC or acute fatigue. Previous studies have shown that loss of sleep was associated with declining mood. The lack of such a relationship in this study may be related to the new regulations. It has been assumed that people can adapt to chronic sleep loss but have a harder time coping with the effects of acute sleep deprivation. If, however, the new regulations have relieved chronic sleep deprivation, then a well-rested resident can periodically cope with the effects of acute sleep deprivation. Perhaps by eliminating chronic sleep debt, work hour restrictions seem to have removed the negative impact of PC seen in the prior era. Further studies should increase the number of residents studied, have numerous repeat NOC and PC pairs in same subjects, compare different services with different workloads, junior and senior residents, and in-house and at-home call schedules.     

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.     

Surgical resident learning styles: faculty and resident accuracy at identification of preferences and impact on ABSITE scores

Introduction

As a consequence of surgical resident duty hour restrictions, there is a need for faculty to utilize novel teaching methods to convey information in a more efficient manner. The current paradigm of surgical training, which has not changed significantly since the time of Halsted, assumes that all residents assimilate information in a similar fashion. However, recent data has shown that learners have preferences for the ways in which they receive and process information. The VARK model categorizes learners as visual (V), aural (A), read/write (R), and kinesthetic (K). The VARK learning style preferences of surgical residents have not been previously evaluated. In this study, the preferred learning styles of general surgery residents were determined, along with faculty and resident perception of resident learning styles. In addition, we hypothesized that American Board of Surgery In-Training Exam (ABSITE) scores are associated with preference for a read/write (R) learning style.

Methods

The Fleming VARK learning styles inventory was administered to all general surgery residents at a university hospital–based program. Responses on the inventory were scored to determine the preferred learning style for each resident. Faculty members were surveyed to determine their accuracy in identifying the preferred learning style of each resident. All residents were also surveyed to determine their accuracy in identifying their peers' VARK preferences. Resident ABSITE scores were examined for association with preferred learning styles.

Results

Twenty-nine residents completed the inventory. Most (18 of 29, 62%) had a multimodal preference, although more than a third (11 of 29, 38%) demonstrated a single-modality preference. Seventy-six percent of all residents (22 of 29) had some degree of kinesthetic (K) learning, while under 50% (14 of 29) were aural (A) learners. Although not significant, dominant (R) learners had the highest mean ABSITE scores. Faculty identified residents' learning styles accurately 41% of the time; more experienced faculty were better than less experienced ones (R² = 0.703, P = 0.018). Residents had similar accuracy to faculty in identifying their peers' learning styles. Chief residents were more accurate than junior residents (44% versus 28%, P = 0.009).

Conclusions

Most general surgery residents have a multimodal learning preference. Faculty members are relatively inaccurate at identifying residents' preferred learning styles; however, there is a strong correlation between years of faculty experience and accuracy. Chief residents are more accurate than junior residents at learning style identification. Higher mean ABSITE scores may be a reflection of a dominant read/write learning style.     

Effect of the 80-hour work week on resident case coverage

BACKGROUND: On July 1, 2003, residency training programs were required to institute restricted duty hours as mandated by the Accreditation Council for Graduate Medical Education. A major concern, voiced by both surgical residents and faculty, was an expectation that this would result in a decrease in operative experience. We hypothesized that implementing restricted duty hours would decrease case coverage by resident trainees. STUDY DESIGN: A retrospective study was performed of operative and endoscopic cases scheduled for a single general surgery practice for a year before and after July 1, 2003. Data collected included operation performed, number of attending surgeons present, whether a resident was present, and level of resident. RESULTS: From July 2002 to June 2003, there were 1,278 cases scheduled; 890 records were available. From July 2004 to June 2005, there were 1,182 cases scheduled; 960 records were available. Before institution of the restricted duty hours, 24.6% of junior-level (PGY1 and 2) cases, 21.7% of intermediate-level (PGY3) cases, and 6.2% of senior-level (PGY4 and 5) cases were not covered by residents. After restricted duty hours were implemented, 27.3% of junior-level cases, 15.9% of intermediate-level cases, and 8.1% of senior-level cases were not covered by residents. Overall 20.8% (185 of 890) and 20.4% (196 of 960) of cases were not covered by residents before and after instituting restricted duty hours, respectively. No difference in case coverage was statistically significant in each category or overall. CONCLUSIONS: Restricted duty hours have not affected resident case coverage.     

Barriers to advancement in academic surgery: views of senior residents and early career faculty

Background

A significant faculty attrition rate exists in academic surgery. The authors hypothesized that senior residents and early-career faculty members have different perceptions of advancement barriers in academic surgery.

Methods

A modified version of the Career Barriers Inventory–Revised was administered electronically to surgical residents and early-career surgical faculty members at 8 academic medical centers.

Results

Residents identified a lack of mentorship as a career barrier about half as often as faculty members. Residents were twice as likely as faculty members to view childbearing as a career barrier.

Conclusions

Many early-career faculty members cite a lack of mentors as a limitation to their career development in academic surgery. Childbearing remains a complex perceived influence for female faculty members in particular. Female faculty members commonly perceive differential treatment and barriers on the basis of their sex. Faculty development programs should address both systemic and sex-specific obstacles if academic surgery is to remain a vibrant field.     

Effect of the 80-hour work week on resident case coverage: corrected article

BACKGROUND: On July 1, 2003, residency training programs were required to institute restricted duty hours as mandated by the Accreditation Council for Graduate Medical Education. A major concern,voiced by both surgical residents and faculty, was an expectation that this would result in a decrease in operative experience. We hypothesized that implementing restricted duty hours would decrease case coverage by resident trainees. STUDY DESIGN: A retrospective study was per formed of operative and endoscopic cases scheduled for a single general surgery practice for a year before and after July 1, 2003. Data collected included operation per formed, number of attending surgeons present, whether a resident was present,and level of resident. RESULTS: From July 2002 to June 2003, there were 1,278 cases scheduled; 890 records were available. From July 2004 to June 2005, there were 1,182 cases scheduled; 960 records were available. Before institution of the restricted duty hours, 24.6% of junior-level (PGY1 and 2) cases, 21.7%of intermediate-level (PGY3) cases, and 6.2% of senior-level (PGY4 and 5) cases were not covered by residents. After restricted duty hours were implemented, 27.3% of junior-level cases,15.9% of intermediate-level cases, and 8.1% of senior-level cases were not covered by residents. Overall 20.8% (185 of 890) and 20.4% (196 of 960) of cases were not covered by residents before and after instituting restricted duty hours, respectively. No difference in case coverage was statistically significant in each category or overall. CONCLUSIONS: Restricted duty hours have not affected resident case coverage.     

Trauma faculty and trauma team activation: impact on trauma system function and patient outcome.

OBJECTIVE: To determine the impact of the presence of an attending trauma surgeon during trauma team activation on system function and patient outcome. METHODS: After a retrospective review of medical records and trauma registry, a comparative study between two American College of Surgeons Committee on Trauma Level I trauma centers was performed. One center (Hennepin County Medical Center) required a chief surgical resident, two junior residents, and a board-certified emergency medicine faculty to be present in the emergency department for all trauma team activations. The attending trauma surgeon was notified at the time of trauma team activation and was neither required to be present in the emergency department at time of patient arrival nor in the hospital 24 h/day. The other center (St. Paul Ramsey Medical Center) required a chief surgical resident, two junior residents, a board-certified emergency medicine faculty member, and an attending trauma surgeon to be present in the emergency department for all trauma activations and in hospital 24 hours/day. Over a 21-month period, all major trauma patients (Injury Severity Score > 15 or emergent operation within 4 hours of admission and any Injury Severity Score) that triggered trauma team activation were examined. Resuscitation time, time to incision, probability of survival, and mortality were analyzed. RESULTS: Resuscitation time was shorter at St. Paul Ramsey Medical Center when compared with Hennepin County Medical Center. Analysis by mechanism of injury demonstrates that this was true for blunt trauma (39+/-13 vs. 27+/-12 minutes, p = 0.001) and for penetrating trauma (28+/-14 vs. 24+/-17 minutes, p = 0.01). Subgroup analysis of penetrating trauma victims demonstrated that there was a significant difference in resuscitation times for gunshot wounds but not for stabs. There was no difference in how quickly operations could be initiated for blunt trauma patients. However, in penetrating cases, time to incision was significantly shorter at St. Paul Ramsey Medical Center (50+/-29 vs. 66+/-43 minutes, p = 0.01). There was no significant difference in mortality for any category of Trauma and Injury Severity Score probability of survival in blunt or penetrating trauma. Analysis of "in-house" and "out-house" time intervals demonstrated no difference in survival in any mechanism of injury, nor was there a difference in overall mortality. CONCLUSION: The presence of a trauma surgeon on the trauma team reduced resuscitation time and reduced time to incision for emergent operations, particularly in penetrating trauma. However, it had no measurable impact on mortality based on Trauma and Injury Severity Score probability of survival. Attending trauma surgeon presence on the trauma team improves in-hospital trauma system function without affecting patient outcome.     

Effect of the 30-hour work limit on resident experience and education

PURPOSE: To evaluate the effect of the 30-hour restriction on resident operative participation and assess whether the 30-hour restriction can be extended in certain cases to enhance educational experience and continuity of care without being detrimental to the 80-hour limit. METHODS: In September 2006, we administered a 10-item Likert scale survey to 41 general surgery residents to assess their experience with the 30-hour work restriction. We also reviewed the operative reports from the busiest general surgery service in April 2003 and April 2005 to assess surgical participation before and after the 30-hour restriction. RESULTS: Twenty-three (56%) residents reported missed operations each month because of the 30-hour restriction. Thirty-four (83%) reported occasions where participating in an operation would require only an additional 1-4 hours. Thirty-six (88%) residents reported a better educational experience when operating on patients whom they had evaluated and a preference to operate on patients whom they had evaluated. The operative log review revealed that in April 2003, the resident assigned to the service participated in 47 out of 134 (35%) total operations and 11 out of 30 (37%) operations beginning after noon. In April 2005, the resident assigned to the service participated in 49 out of 109 (45%) total operations and 20 out of 45 (44%) of the operations beginning after noon. CONCLUSION: The difference in the amount of operations involving resident participation before and after the 30-hour restriction, including afternoon cases that would be most affected by the work restriction, was minimal. However, we identified occasions when the 30-hour work restriction could be extended to provide continuity of care and a better educational operative experience while maintaining weekly duty hours within the approved limit. Extensions beyond the 30 hours should be limited to providing unique and comprehensive experiences for residents where the additional time or episodes would not cause resident fatigue.     

A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours

BACKGROUND: Adoption of limits on resident work hours prompted us to develop a centralized, Web-based computerized rounding and sign-out system (UWCores) that securely stores sign-out information; automatically downloads patient data (vital signs, laboratories); and prints them to rounding, sign-out, and progress note templates. We tested the hypothesis that this tool would positively impact continuity of care and resident workflow by improving team communication involving patient handovers and streamlining inefficiencies, such as hand-copying patient data during work before rounds ("prerounds"). STUDY DESIGN: Fourteen inpatient resident teams (6 general surgery, 8 internal medicine) at two teaching hospitals participated in a 5-month, prospective, randomized, crossover study. Data collected included number of patients missed on resident rounds, subjective continuity of care quality and workflow efficiency with and without UWCores, and daily self-reported prerounding and rounding times and tasks. RESULTS: UWCores halved the number of patients missed on resident rounds (2.5 versus 5 patients/team/month, p = 0.0001); residents spent 40% more of their prerounds time seeing patients (p = 0.36); residents reported better sign-out quality (69.6% agree or strongly agree); and improved continuity of care (66.1% agree or strongly agree). UWCores halved the portion of prerounding time spent hand-copying basic data (p < 0.0001); it shortened team rounds by 1.5 minutes/patient (p = 0.0006); and residents reported finishing their work sooner using UWCores (82.1% agree or strongly agree). CONCLUSIONS: This system enhances patient care by decreasing patients missed on resident rounds and improving resident-reported quality of sign-out and continuity of care. It decreases by up to 3 hours per week (range 1.5 to 3) the time used by residents to complete rounds; it diverts prerounding time from recopying data to more productive tasks; and it facilitates meeting the 80-hour work week requirement by helping residents finish their work sooner.     

Interscalene block using ultrasound guidance: impact of experience on resident performance

Background: We evaluated the weekly progress of anesthesiology residents performing an interscalene block with ultrasound guidance (UG) for block success rates and for the specific time intervals: (i) time to image the brachial plexus and (ii) time from insertion of the block needle until motor stimulation occurred. Our primary objective was to characterize the influence of experience over the course of the regional anesthesia rotation on the performance of a UG interscalene block by anesthesiology residents.
Methods: Residents conducted an interscalene block with UG under the supervision of attending anesthesiologists experienced in this technique. Block efficacy, time intervals required to perform the block, and acute complications were recorded. We compared success rates over the course of the rotation, and analyzed process time data with respect to trainee level of experience, week of the trainee rotation, and patient body habitus.
Results: Twenty-one trainees conducted 222 blocks over a consecutive 7-month period. Block success rate was 97.3%, and did not change significantly over the course of the 4-week rotation. Total block time and imaging time significantly decreased over the 4-week rotation, while the needle insertion-to-stimulation time did not change. Slower imaging time was predicted by obesity.
Conclusion: The success rates for a UG interscalene block provided by supervised residents were initially high, and remained so throughout the 4-week rotation. Trainees required less time to image the nerves and to perform the block over the course of the rotation.     

CAGS AND ACS EVIDENCE BASED REVIEWS IN SURGERY. 45: Impact of the 80-hour resident work week on mortality and morbidity in trauma patients

Question: Has the implementation of the resident work hours restriction of 80 hours per week impacted on mortality of injured patients and the resources used to care for them? Design: Retrospective cohort study. Data source: National Trauma Data Bank (NTDB) version 6.2. Results: Overall mortality decreased from 4.64% in the pre–80 hour work week to 4.46% in the post–80 hour week (p < 0.001). Of particular interest were the differences in outcomes observed in academic versus non-academic institutions. In university hospitals, the mortality decreased from 5.16% to 5.03% (p = 0.03), whereas in nonteaching hospitals, mortality increased from 3.38% to 3.85% (p < 0.001). There were also small but statistically significant improvements seen in secondary outcomes during the post–80 hour work week. Conclusion: The 80-hour work week has not resulted in significant deterioration in the outcome of injured patients.     

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.