Impact of Work-Hour Restrictions on Residents’ Operative Volume on a Subspecialty Surgical Service

A Dual-Institutional Study on First Year Practice Outcomes of Pediatric Surgeons Who Trained in the Era of Work Hour Restrictions

BACKGROUND

In July 2003, an 80-h work week restriction for residencies was mandated. This was met with skepticism regarding its potential impact on operative training. We hypothesized no difference in outcomes for pediatric surgeons who trained under duty hour restrictions compared to historical complication rates.

METHODS

Dual-institutional review of pediatric patients who underwent five of the most common operations (2013-2018) by first-year pediatric surgeons who trained under duty hour restrictions was performed. Tests of proportions were used to compare complication rates to published rates on data collected prior to 2003.

RESULTS

Patient mean age was 10.1 years. No significant differences (p values > 0.05) were found in laparoscopic appendectomy rates of infection, bleeding or intra-abdominal abscess compared to previously published rates. Pyloromyotomy rates of infection or duodenal perforation were not different. No differences were detected in rates of infection, recurrence or testicular atrophy for inguinal hernia repair. Umbilical hernia rates of infection, bleeding, and recurrence were also not different. There was no difference in CVC rates of hemopneumothoraces; significantly more bleeding events were detected (1.2% vs. 0.1%; p value = 0.04).

CONCLUSION

In this study, first-year complication rates of pediatric surgeons who trained under duty hour restrictions were not significantly different when compared to published rates.

The Role of Senior Resident Clinics in Plastic Surgery Education in Canada

Background

Senior resident clinics are a means to encourage independent practice and problem solving and enhance surgical skills. The objective of this study is to investigate senior resident clinics across Canada and their utility in providing comprehensive plastic surgery training.

Methods

A web-based survey was sent to all plastic surgery program directors (PDs) and senior residents (SRs; postgraduate years 3, 4, and 5) across Canada. The surveys focused on demographics, clinic structure, procedures commonly performed, perceived autonomy, educational benefit, competency-based design considerations, and areas for improvement. Chi-square tests were used to compare responses between PDs and SRs.

Results

A total of 10 PDs (100% response rate) and 26 SRs (41% response rate) responded. Half of the training programs across Canada currently have senior clinics, and the format varies between institutions. Clinics generally focus on hand trauma and aesthetics. Both PDs and SRs felt that there is considerable autonomy for resident care in both the pre/post-operative and operative setting. Common barriers to implementing a senior clinic include not enough staff, not enough time, and the medicolegal risk. Most core competencies are felt to be addressed through the use of senior clinics. Methods to improve senior clinics could include more regular and higher volume clinics, enhanced equipment, and separation of hand and aesthetics clinics.

Conclusions

Senior clinics are a useful method to improve plastic surgery education and address many core aspects of plastic surgery training. Implementation of supported clinics focused on hand and aesthetics surgery separately may be useful for training programs that currently lack a senior clinic.

(Re)thinking the Residential in Residency: Modern Surgical Practice Continues to Move Away From the Inpatient Setting

PURPOSE

Despite the overall shift in care delivery to an ambulatory setting, the majority of general surgical education still relies on the experience of caring for inpatients. We aimed to investigate how the inpatient practice patterns of newly minted general surgeons (GS) have changed since 2008, in order to better inform education policies regarding both training approach and setting for modern surgical trainees.

METHODS

State discharge data from NY and FL (2008-2017) were linked to data on GS from the American Medical Association Masterfile, and to hospital data from the American Hospital Association annual survey. Mean annual inpatient case volume (CV) and case type breadth (CB) were compared between surgeons who were new-to-practice (0-3 years of experience) in 2008 and in 2013. Each new surgeon cohort was followed for 5 years. Case type was classified by organ system.

RESULTS

The 2008 cohort included 328 GS with a mean age of 37.1, 79.6% male and 94.2% board-certified. The 2013 cohort included 359 GS with a mean age of 36.2, 73.0% male and 93.9% board-certified. CV was higher among the 2008 cohort than the 2013 cohort for each year of practice in the study period. CB included at least 4 organ system types for all new GS with greater breadth among the 2008 cohort for each year in the study period.

CONCLUSIONS

Declining rates of inpatient surgery affect general surgeons who were new-to-practice in 2013 significantly more than those entering practice only 5 years ahead of them. New surgeons continue to start their practices broadly, suggesting a need to continue broad training while expanding formal educational policies to include the full spectrum of ambulatory surgery.

A Formal Work Hour Analysis of the Resident Foot and Ankle Surgeon

As new documentation requirements by governments and third-party payees increasingly occupy physicians' time, duty hour restrictions have continued to restrict the work hours of residents, leaving programs tasked to produce proficient foot and ankle surgeons (FASs) in less time. The purpose of the present study was to quantify the workday of resident FASs at our institution to identify areas suited for revision to improve efficiency and training. A resident from each postgraduate year (PGY) was recruited and consented for minute-to-minute observation by 4 independent observers over 5 consecutive workdays. The time recorded was placed into a predefined work model consisting of 9 categories (education, research, operating room, patient care, documentation/administration, communications, transit, basic needs, and standby) within 1 of 3 value groups (positive, neutral, or negative). A fifth independent observer reviewed and recorded all collected data. Over 5 consecutive days, ancillary staff frequently disrupted the PGY-1 resident's workflow. The interruptions fragmented the resident's thoughts, increased inefficiency, and resulted in the largest proportion of the resident's time (16.7%) being occupied by documentation/administration duties. For the PGY-2 and PGY-3 residents, unexpected trends in standby were identified during the preoperative period. Secondary analysis revealed that during unexpected preoperative delays, resident efficiency was poor. To maximize efficiency and improve training, residents must increase their awareness of self-inefficiency while minimizing unnecessary interruptions and the time occupied by duties of lesser value. It is our hope that the present study will aid other institutions in facilitating similar improvements to the education and training of our fellow resident FASs.

Causes of resident lapses in professional conduct during the training: A qualitative study on the perspectives of residents

BACKGROUND

The residency is a critical period for doctors to establish their professional identity and ethical standards, and yet during this time, residents are susceptible to engage in a diverse range of unprofessional behaviors. To prevent the misconduct of residents, it is critical to have a thorough understanding of the contributing factors or circumstances.

METHODS

We conducted a qualitative study on 20 residents at one Korean university-affiliated tertiary hospital. During in-depth interviews, residents were asked to reveal their experiences or observations of misconduct, and describe their perceptions on the attributes of professional lapses.

RESULTS

Diverse unethical and unprofessional behaviors were extracted from the transcripts and reported in a previous paper. In the current paper, the attributes that residents regarded as the causes of their unprofessional behaviors were identified within four categories: (1) inadequate systems within training hospitals; (2) lack of professionalism education; (3) strong hierarchical structure; and (4) poor character of individuals. The residents tended to perceive their misconduct as situation-sensitive, and emphasized the importance of systematic and cultural changes.

CONCLUSIONS

To enhance medical professionalism among residents, the results of this study suggest the need of systematic and structured training programs, adequate professionalism education with clear codes of conduct, and active monitoring and feedback systems.

A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes

BACKGROUND

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated 80-hour resident duty limits. In 2011 the ACGME mandated 16-hour duty maximums for PGY1 (post graduate year) residents. The stated goals were to improve patient safety, resident well-being, and education. A systematic review and meta-analysis were performed to evaluate the impact of resident duty hours (RDH) on clinical and educational outcomes in surgery.

METHODS

A systematic review (1980-2013) was executed on CINAHL, Cochrane Database, Embase, Medline, and Scopus. Quality of articles was assessed using the GRADE guidelines. Sixteen-hour shifts and night float systems were analyzed separately. Articles that examined mortality data were combined in a random-effects meta-analysis to evaluate the impact of RDH on patient mortality.

RESULTS

A total of 135 articles met the inclusion criteria. Among these, 42% (N = 57) were considered moderate-high quality. There was no overall improvement in patient outcomes as a result of RDH; however, some studies suggest increased complication rates in high-acuity patients. There was no improvement in education related to RDH restrictions, and performance on certification examinations has declined in some specialties. Survey studies revealed a perception of worsened education and patient safety. There were improvements in resident wellness after the 80-hour workweek, but there was little improvement or negative effects on wellness after 16-hour duty maximums were implemented.

CONCLUSIONS

Recent RDH changes are not consistently associated with improvements in resident well-being, and have negative impacts on patient outcomes and performance on certification examinations. Greater flexibility to accommodate resident training needs is required. Further erosion of training time should be considered with great caution.

Is current surgical training efficient? A national survey

OBJECTIVES

Evaluation of surgical training in Denmark is competency based with no requirement for a specific number of procedures. This may affect monitoring of surgical progress adversely and cause an underestimation of the time needed to acquire surgical competencies. We investigated the number of common surgical procedures performed by trainees. Trainees' and consultants' expectations from the training program were also investigated.

DESIGN AND PARTICIPANTS

A questionnaire was sent to all 115 surgical trainees in Denmark. We asked how many common surgical procedures the trainees had performed during their postgraduate training, whether self-reported procedural confidence was achieved during their training, and whether their training expectations were met. Another questionnaire dealt with the consultants' expectations of the surgical training.

RESULTS

The total number of common surgical procedures (Lichtenstein hernia repair, appendectomy, laparoscopic appendectomy, and laparoscopic cholecystectomy) that were performed varied between trainees. One group performed few common procedures during training. A low number in 1 procedure correlated with a similar pattern in other procedures. Approximately one-third did not perform common elective procedures independently until their fifth year. Consultants and trainees viewed training differently.

CONCLUSIONS

Our study reveals no common trend in the numbers and types of procedures performed during training. The number of procedures seems to reflect the individual trainee and a local tradition rather than the particular training program. An informal competency-based assessment system with lack of quantitative requirements evidently involves a risk of skewness in training.

Duty hours and home call: the experience of plastic surgery residents and fellows

BACKGROUND

Although resident duty hours are strictly regulated by the Accreditation Council for Graduate Medical Education, there are fewer restrictions on at-home call for residents. To date, no studies have examined the experience of home call for plastic surgery trainees or the impact of home call on patient care and education in plastic surgery.

METHODS THE AUTHORS DISTRIBUTED

an anonymous electronic survey to plastic surgery trainees at 41 accredited programs. They sought to produce a descriptive assessment of home call and to evaluate the perceived impact of home call on training and patient care.

RESULTS

A total of 214 responses were obtained (58.3 percent completion rate). Nearly all trainees reported taking home call (98.6 percent), with 66.7 percent reporting call frequency every third or fourth night. Most respondents (63.3 percent) felt that home call regulations are vague but that Council regulation (44.9 percent) and programmatic oversight (56.5 percent) are adequate. Most (91.2 percent) believe their program could not function without home call and that home call helps to avoid strict duty hour restrictions (71.5 percent). Nearly all respondents (92.3 percent) preferred home call to in-house call.

CONCLUSIONS

This is the first study to examine how plastic surgery residents experience and perceive home call within the framework of Accreditation Council for Graduate Medical Education duty hour regulations. Most trainees feel the impact of home call is positive for education (50.2 percent) and quality of life (56.5 percent), with a neutral impact on patient care (66.7 percent). Under the Council's increasing regulations, home call provides a balance of education and patient care appropriate for training in plastic and reconstructive surgery.

Orthopedic resident work-shift analysis: are we making the best use of resident work hours?

BACKGROUND

Surgery programs have been tasked to meet rising demands in patient surgical care while simultaneously providing adequate resident training in the midst of increasing resident work-hour restrictions. The purpose of this study was to quantify orthopedic surgery resident workflow and identify areas needing improved resident efficiency. We hypothesize that residents spend a disproportionate amount of time involved in activities that do not relate directly to patient care or maximize resident education.

METHODS

We observed 4 orthopedic surgery residents on the orthopedic consult service at a major tertiary care center for 72 consecutive hours (6 consecutive shifts). We collected minute-by-minute data using predefined work-task criteria: direct new patient contact, direct existing patient contact, communications with other providers, documentation/administrative time, transit time, and basic human needs. A seventh category comprised remaining less-productive work was termed as standby.

RESULTS

In a 720-minute shift, residents spent on an average: 191 minutes (26.5%) performing documentation/administrative duties, 167.0 minutes (23.2%) in direct contact with new patient consults, 129.6 minutes (17.1%) in communication with other providers regarding patients, 116.2 (16.1%) minutes in standby, 63.7 minutes (8.8%) in transit, 32.6 minutes (4.5%) with existing patients, and 20 minutes (2.7%) attending to basic human needs. Residents performed an additional 130 minutes of administrative work off duty. Secondary analysis revealed residents were more likely to perform administrative work rather than directly interact with existing patients (p = 0.006) or attend to basic human needs (p = 0.003).

CONCLUSIONS

Orthopedic surgery residents spend a large proportion of their time performing documentation/administrative-type work and their workday can be operationally optimized to minimize nonvalue-adding tasks. Formal workflow analysis may aid program directors in systematic process improvements to better align resident skills with tasks.

LEVEL OF EVIDENCE

III.

ACGME case logs: Surgery resident experience in operative trauma for two decades

BACKGROUND

Surgery resident education is based on experiential training, which is influenced by changes in clinical management strategies, technical and technologic advances, and administrative regulations. Trauma care has been exposed to each of these factors, prompting concerns about resident experience in operative trauma. The current study analyzed the reported volume of operative trauma for the last two decades; to our knowledge, this is the first evaluation of nationwide trends during such an extended time line.

METHODS

The Accreditation Council for Graduate Medical Education (ACGME) database of operative logs was queried from academic year (AY) 1989-1990 to 2009-2010 to identify shifts in trauma operative experience. Annual case log data for each cohort of graduating surgery residents were combined into approximately 5-year blocks, designated Period I (AY1989-1990 to AY1993-1994), Period II (AY1994-1995 to AY1998-1999), Period III (AY1999-2000 to AY2002-2003), and Period IV (AY2003-2004 to AY2009-2010). The latter two periods were delineated by the year in which duty hour restrictions were implemented.

RESULTS

Overall general surgery caseload increased from Period I to Period II (p < 0.001), remained stable from Period II to Period III, and decreased from Period III to Period IV (p < 0.001). However, for ACGME-designated trauma cases, there were significant declines from Period I to Period II (75.5 vs. 54.5 cases, p < 0.001) and Period II to Period III (54.5 vs. 39.3 cases, p < 0.001) but no difference between Period III and Period IV (39.3 vs. 39.4 cases). Graduating residents in Period I performed, on average, 31 intra-abdominal trauma operations, including approximately five spleen and four liver operations. Residents in Period IV performed 17 intra-abdominal trauma operations, including three spleen and approximately two liver operations.

CONCLUSION

Recent general surgery trainees perform fewer trauma operations than previous trainees. The majority of this decline occurred before implementation of work-hour restrictions. Although these changes reflect concurrent changes in management of trauma, surgical educators must meet the challenge of training residents in procedures less frequently performed.

LEVEL OF EVIDENCE

Epidemiologic study, level III; therapeutic study, level IV.

Changes in residents' opportunities for experiential learning over time

CONTEXT

Learning in the clinical environment is believed to be a crucial component of residency training. However, it remains unclear whether recent changes to postgraduate medical education, including the implementation of work hour limitations, have significantly impacted opportunities for experiential learning. Therefore, we sought to quantify opportunities to gain clinical experience within medical-surgical intensive care units (ICUs) over time.

METHODS

Data on the numbers of patients admitted and invasive procedures performed per day between 1 July 2001 and 30 June 2010 within three academic medical-surgical ICUs in Calgary, Alberta, Canada were obtained from electronic medical records. These data were matched to resident doctor on-call schedules and residents' opportunities to admit patients and participate in procedures were calculated and compared over time using Spearman's rho.

RESULTS

We found that over a 9-year period, the opportunities afforded to residents (n = 1156) to admit patients (n = 17 189) and perform procedures (n = 52 827) during ICU rotations decreased by 32% (p < 0.001) and 34% (p < 0.001), respectively.

CONCLUSIONS

Our results suggest that there has been a significant decrease in residents' clinical experiences in the ICU over time. Further investigations to better understand these changes and how they may impact on performance as residents become independent practising doctors are warranted.

Effect of the new standards for case logging on resident operative volume: doing better cases or better numbers?

OBJECTIVES

The Accreditation Council for Graduate Medical Education (ACGME) modified the designation of major (index) operative cases to include those previously considered "minor." This study assessed the potential effect of these changes on resident operative experience.

METHODS

With Institutional Review Board approval, we analyzed National Surgical Quality Improvement Program participant use files for 2005-2008 for general and vascular surgery cases. Primary CPT case coding was mapped to the ACGME major case category using both the old and new classification schemes. The variables were analyzed using χ(2) analysis in SPSS IBM 19 (IBM, Armonk, New York).

RESULTS

A total of 576,019 cases were reviewed. Major cases as defined by the new classification represented an increasing proportion of the cases each year, rising from 88.3% in 2005 to 95% by 2008 (p < 0.001). Major cases as defined by the old scheme decreased from 71% in 2005 to 62% by 2008 (p < 0.001). The cases covered by a resident dropped from 82% in 2005 to 61% in 2008 (p < 0.001). When comparing the new to the old scheme, 364,366 (63.3%) cases were considered major and 30,587 (5.3%) were minor by both standards; 7089 (1.2%) cases previously classified as major were changed to minor, whereas 173,977 (30.2%) (p < 0.001) previously classified as minor were now major. This latter group showed top procedures to include excision of breast lesion (22,175 [12.7%]), laparoscopic gastric bypass (18,825 [10.8%]), ventral hernia repair (14,732 [8.5%]), and appendectomy (10,190 [5.9%]). Of these newly designated major cases, the proportion not covered by residents increased from 22% in 2005 to 44% in 2007 and 2008 (p < 0.001).

CONCLUSIONS

Although some operative cases newly classified as major are technically advanced procedures (eg, Roux-en-Y gastric bypass), other cases are not (eg, breast lesion excision), which raises the issue as to whether the major case category has been diluted by less demanding case types. The implications of these findings may suggest preservation of case volumes at the expense of case quality.

Orthopaedic resident and program director opinions of resident duty hours: a national survey

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) established national guidelines for resident duty hours in July 2003. Following an Institute of Medicine report in December 2008, the ACGME recommended further restrictions on resident duty hours that went into effect in July 2011. We conducted a national survey to assess the opinions of orthopaedic residents and of directors of residency and fellowship programs in the U.S. regarding the 2003 and 2011 ACGME resident duty-hour regulations and the effects of these regulations on resident education and patient care.

METHODS

A fifteen-item questionnaire was electronically distributed by the Candidate, Resident, and Fellow Committee of the American Academy of Orthopaedic Surgeons (AAOS) to all U.S. orthopaedic residents (n = 3860) and directors of residency programs (n = 184) and fellowship programs (n = 496) between January and April 2011. Thirty-four percent (1314) of the residents and 27% (185) of the program directors completed the questionnaire. Statistical analyses were performed to detect differences between the responses of residents and program directors and between the responses of junior and senior residents.

RESULTS

The responses of orthopaedic residents and program directors differed significantly (p &lt; 0.001) for fourteen of the fifteen survey items. The responses of residents and program directors were divergent for questions regarding the 2003 rules. Overall, 71% of residents thought that the eighty-hour work week was appropriate, whereas only 38% of program directors agreed (p &lt; 0.001). Most program directors (70%) did not think that the 2003 duty-hour rules had improved patient care, whereas only 24% of residents responded in the same way (p &lt; 0.001). The responses of residents and program directors to questions regarding the 2011 duty-hour rules were generally compatible, but the degree to which they perceived the issues was different. Only 18% of residents and 19% of program directors thought that the suggested strategic five-hour evening rest period implemented in July 2011 for on-call residents was appropriate (p &gt; 0.05), and both groups (84% of residents and 74% of program directors) also disagreed with the limitation of intern shifts to sixteen hours (p &lt; 0.001). Seventy percent of residents and 79% of program directors thought that the new duty-hour regulations would result in an increased number of handoffs that would be detrimental to patient care (p &lt; 0.001). The mean responses of junior residents and senior residents differed for eight of the fifteen survey items (p &lt; 0.001), with the responses of senior residents more closely resembling those of program directors on six of these eight questions. The mean responses and percentiles for the survey items did not differ significantly between residency directors and fellowship directors (p &gt; 0.05).

CONCLUSIONS

This national survey indicated significant differences between the opinions of orthopaedic residents and program (residency and fellowship) directors regarding the 2003 ACGME resident duty-hour regulations and the effects of these regulations on resident education and patient care. However, both residents and program directors agreed that the further reductions in duty hours in the 2011 rules may be detrimental to resident education and patient care.

Resident fatigue in 2010: where is the beef?

BACKGROUND

The Accreditation Council for Graduate Medical Education Common Program Requirements for all residency programs (effective July 1, 2011) will limit postgraduate year-1 duty hour length to 16 hours of call. Previous studies have shown some decrement in post-call task performance. We designed a study to evaluate if these decrements still exist in 2010 and to determine specifically when they occur.

METHODS

Fourteen residents were tested on 4 simulator tasks during 5 separate call periods. These tasks were completed serially at 4 different time (T) intervals (T0, T12, T18, and T24) over a 24-hour period. Task performance was measured at each of these intervals. The residents completed a post-call survey.

RESULTS

Over the 24-hour call there was a trend toward decreased time for the completion of tasks with preservation of accuracy and efficiency. The performance of some residents actually improved and there was minimal correlation between perceived fatigue and performance.

CONCLUSIONS

These data show no decrease in junior or senior resident task performance over a 24-hour call period, and do not support the 2011 Accreditation Council for Graduate Medical Education maximum duty hour length of 16 hours.

Resident duty-hour restrictions and their effect on operative experience in obstetrics and gynecology

BACKGROUND/AIMS

To determine the effect of duty-hour restrictions on the operative experience of obstetrics and gynecology residents.

METHODS

Operative numbers were obtained from graduates of Mayo Clinic (Rochester, Minn., USA) and Good Samaritan Hospital (Cincinnati, Ohio, USA). Mean operative numbers between graduates in 2007 and 2003 were compared. The following procedures were evaluated: spontaneous vaginal delivery, forceps-assisted vaginal delivery, vacuum-assisted vaginal delivery, cesarean delivery, surgery on antenatal patients, amniocentesis, total abdominal hysterectomy, total vaginal hysterectomy, laparotomy, incontinence or pelvic floor surgery, operative laparoscopy, hysteroscopy, cervical conization, and surgical sterilization. The number of procedures performed (total and as the primary surgeon) were evaluated. We analyzed each institution's residents separately.

RESULTS

At Mayo Clinic, the 2007 graduates performed significantly fewer conizations than the 2003 graduates (p = 0.006). At Good Samaritan Hospital, the 2007 graduates performed significantly more vacuum-assisted vaginal deliveries (p = 0.002), cesarean deliveries (p = 0.002), and sterilizations (p < 0.001) than the 2003 graduates. The above findings were unchanged when evaluating procedures for which the resident was the primary surgeon.

CONCLUSION

Duty-hour restrictions have not adversely affected the operative experience of obstetrics and gynecology residents. No significant differences in the number of the spontaneous vaginal deliveries, abdominal hysterectomies, or vaginal hysterectomies performed were observed.

Patient safety, resident education and resident well-being following implementation of the 2003 ACGME duty hour rules

CONTEXT

The ACGME-released revisions to the 2003 duty hour standards.

OBJECTIVE

To review the impact of the 2003 duty hour reform as it pertains to resident and patient outcomes.

DATA SOURCES

Medline (1989-May 2010), Embase (1989-June 2010), bibliographies, pertinent reviews, and meeting abstracts.

STUDY SELECTION

We included studies examining the relationship between the pre- and post-2003 time periods and patient outcomes (mortality, complications, errors), resident education (standardized test scores, clinical experience), and well-being (as measured by the Maslach Burnout Inventory). We excluded non-US studies.

DATA EXTRACTION

One rater used structured data collection forms to abstract data on study design, quality, and outcomes. We synthesized the literature qualitatively and included a meta-analysis of patient mortality.

RESULTS

Of 5,345 studies identified, 60 met eligibility criteria. Twenty-eight studies included an objective outcome related to patients; 10 assessed standardized resident examination scores; 26 assessed resident operative experience. Eight assessed resident burnout. Meta-analysis of the mortality studies revealed a significant improvement in mortality in the post-2003 time period with a pooled odds ratio (OR) of 0.9 (95% CI: 0.84, 0.95). These results were significant for medical (OR 0.91; 95% CI: 0.85, 0.98) and surgical patients (OR 0.86; 95% CI: 0.75, 0.97). However, significant heterogeneity was present (I(2) 83%). Patient complications were more nuanced. Some increased in frequency; others decreased. Outcomes for resident operative experience and standardized knowledge tests varied substantially across studies. Resident well-being improved in most studies.

LIMITATIONS

Most studies were observational. Not all studies of mortality provided enough information to be included in the meta-analysis. We used unadjusted odds ratios in the meta-analysis; statistical heterogeneity was substantial. Publication bias is possible.

CONCLUSIONS

Since 2003, patient mortality appears to have improved, although this could be due to secular trends. Resident well-being appears improved. Change in resident educational experience is less clear.

The Impact of ACGME Work-Hour Reforms on the Operative Experience of Fellows in Surgical Subspecialty Programs

BACKGROUND

In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) introduced a set of regulations that mandated a reduction in the number of hours that medical residents can work. These requirements have generated controversy among medical educators, with some expressing concern that reducing resident hours may limit clinical exposure and competency, particularly in surgical specialties.

OBJECTIVE

This study examines the impact of duty hour restrictions on resident operative experience in residents in 2 surgical subspecialties since the implementation of the ACGME duty hour limits.

METHOD

We examined operative log data for vascular surgery and pediatric surgery, using the academic year immediately preceding the duty hour restrictions, 2002 to 2003, as a baseline for comparison to subsequent academic years through 2006 to 2007 for vascular surgery and 2007 to 2008 for pediatric surgery.

RESULTS

Graduating fellows in pediatric surgery showed no change in their total operative volume following duty hour restrictions. The pediatric-defined category of neonate procedures showed an increase following duty hour restrictions. Graduating fellows in vascular surgery showed an increase in total major procedures as surgeon. The vascular-defined categories of endovascular-diagnostic, endovascular-therapeutic, and endovascular-graft procedures also increased.

CONCLUSIONS

The reduction of duty hours has not resulted in a decrease in operative volume as some have predicted. Operative volume in pediatric surgery remained mainly unchanged, whereas operative volume in vascular surgery increased. We explore possible explanations for the observed findings.

Effect of the ACGME duty hours restrictions on surgical residents and faculty: a systematic review

PURPOSE

Educators in surgical training programs are concerned that the Accreditation Council for Graduate Medical Education (ACGME) duty hours limitations may adversely affect surgical residents' education, especially their operative experience, so the authors aimed to evaluate the impact of duty hours reductions on surgical residency.

METHOD

The authors searched English- and French-language literature (2000-2008) for articles about the impact of duty hours restrictions on surgical residents' education and well-being and on faculty educators. They used the following databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and ERIC. The authors included every report that examined the effects of duty hours limits on surgical training, excluding opinion papers and editorials. Two reviewers independently performed data extraction and quality assessment for all reports and resolved disagreements by consensus.

RESULTS

The authors retrieved 1,146 reports and included 56 in the study. They compiled positive and negative outcomes on (1) residents' education, (2) resident lifestyle, and (3) surgical faculty. Overall, the effects of duty hours reductions on residents' education and lifestyle were positive or neutral, but the effects on surgical faculty were negative. The 16 articles with the highest-quality scores had 27 positive themes and 11 negative themes.

CONCLUSIONS

This is the largest and most current review of the literature addressing the effect of the ACGME duty hours limitations on surgical training. Limitations had a positive effect on residents but a negative effect on surgical faculty. Importantly, duty hours limitations did not adversely affect surgical residents' operating-room experience.

Surgical training: the impact of changes in curriculum and experience

INTRODUCTION

Craft specialties, such as surgery, rely on practice to acquire skill. Yet recent changes in training in the United Kingdom have decreased experience and altered the balance of curriculum content. Most recently, the European Working Time Directive has led to a reduction in working hours and expansion in the number of trainees. The impact that these changes have had on operative experience, patient management, communication, and teaching skills is unclear. This study aims to assess the effects of the changing curriculum and work patterns on the experience of trainees at senior house officer (SHO, equivalent to junior resident) level in general surgery.

METHODS

A structured questionnaire was sent to general surgery trainees at the SHO (n = 52) and specialist registrar (SpR, n = 69) levels (equivalent to senior resident) in the Severn Deanery, United Kingdom.

RESULTS

In all, 70% of both SHOs and SpRs responded. SpRs had spent a mean of 50 months (21 months in general surgery) at the SHO level, compared with 24 months (9 months in general surgery) for current SHOs. A total of 90% of SpRs could perform an open appendectomy unsupervised by the end of their SHO training, compared with 28% of current SHOs. In all, 63% of SpRs and 8% of SHOs could undertake inguinal hernia repair unsupervised at SHO level. In addition, 90% of SpRs and 84% of SHOs felt operative skills have declined, whereas communication and teaching skills were deemed the same or better. Of the respondents, 88% of SpRs and 76% of SHOs thought surgical training was getting worse.

DISCUSSION

Trainees are spending less time in surgery at the SHO level, and this is reflected in reported operative ability. The introduction of communication and teaching skills into the curriculum has had a perceived benefit. The reduction in working hours must be offset by implementing measures to maximize limited training opportunities. The potential implications of these changes in training and experience on patient outcomes remain to be determined.

Operative volume in the new era: a comparison of resident operative volume before and after implementation of 80-hour work week restrictions

OBJECTIVE

To determine the effect of the 80-hour work week restrictions on general surgery resident operative volume in a large, community-based, university-affiliated, general surgery residency program.

METHODS

We performed a retrospective review of Accreditation Council for Graduate Medical Education (ACGME) operative logs of general surgery residents graduating from a single residency. The control group consisted of the residents graduating in the 3 years prior to the work-hour restriction implementation (2001, 2002, and 2003). Our comparison group consisted of those residents graduating in the first 2 classes whose entire residency was conducted after the implementation of the 80-hour work week (2008 and 2009). Comparisons were made between the control and the comparison groups in the 19 ACGME defined categories, total number of major cases, total number of chief cases, and total number of teaching assist cases.

RESULTS

Operative volumes in 13 categories (skin/soft tissue/breast, alimentary tract, abdominal, liver, pancreas, vascular, endocrine, pediatrics, endoscopy, laparoscopic-complex, total chief cases, total major cases, and teaching cases) were not significantly affected by the implementation of the 80-hour work week. One of the 19 categories (laparoscopic-basic) showed a significant increase in operative volume (p < 0.0001). In 4 of the 19 categories (head/neck, operative-trauma, thoracic, and plastics), operative volume was significantly decreased in the post-80-hour work week era (p < 0.05). Nonoperative trauma could not be assessed, as the category did not exist before the work-hour restrictions.

CONCLUSIONS

Resident operative volume at our institution's general surgery residency program largely has been unaffected by implementation of the 80-hour work week. Residencies in general surgery can be structured in a manner to allow for compliance with duty-hour regulations while maintaining the required operative volume outlined by the ACGME defined categories.

Evaluation of a transition to practice program for neurosurgery residents: creating a safe transition from resident to independent practitioner

BACKGROUND

In 2004, the Department of Neurosurgery at the University of Florida implemented a major curriculum innovation called the Transition to Practice program. This program was established to prepare residents to more safely transition to the role of independent practitioner.

METHODS

A qualitative and quantitative evaluation of the program was conducted after its fifth year using online surveys and interviews. Study participants included Transition to Practice graduates, faculty, and current residents.

RESULTS

Of the 26 respondents, 89% of faculty and all graduates were very satisfied with the program. Strengths identified included an independent yet mentored broad operative experience, the development of self-confidence, and a real sense of responsibility for patients. Medical billing and coding instruction and career mentoring were areas of the program that required additional attention.

CONCLUSION

Overall, this program is meeting the stated objectives and is well received by the graduates and faculty. Based on the results of this evaluation, curricular changes such as instructions in practice management and implementation of a career-mentoring program have occurred. The Transition to Practice program is a unique curricular response to change that other surgical specialties may find useful in addressing the current-day stresses on graduate medical education.

A national survey of pediatric residents and delivery room training experience

OBJECTIVE

To investigate current delivery room training experience in US pediatric residency programs and the relationship between volume of delivery room training and confidence in neonatal resuscitation skills.

STUDY DESIGN

Links to a web-based survey were sent to pediatric residency programs and distributed to residents. The survey concerned delivery room attendance during training and comfort level in leading neonatal resuscitation for various scenarios. Comfort level was rated on a 1 to 9 scale. Mixed models accounted for residency programs as random effects.

RESULTS

For PL-3s, the mean number of deliveries attended was 60 (standard deviation, 43), ranging from 13 to 143 deliveries for individual residency programs. Residents' confidence level in leading neonatal resuscitation was higher when attending more deliveries, with 90.3% of those attending>48 deliveries having average score 5 or greater vs 51.5% of those attending<21 deliveries. Higher attendance also correlated with confidence in endotracheal intubation and umbilical line placement.

CONCLUSIONS

Wide variability existed within and among residency programs in number of deliveries attended. Volume of experience correlated with confidence in leading neonatal resuscitation and related procedural skills.

Commentary: the case for expanding general surgery residencies

Despite the significant growth in population in the United States since 1980 and societal and demographic factors such as an aging population, there has been no increase in the number of graduating general surgery residents each year, which has created a worsening shortage of general surgeons. Other factors, such as stricter duty hours requirements and an increase in the number and variety of procedures general surgeons must perform, have also contributed to this shortage. Yet, applicant demand for general surgery positions is currently strong and will increase as new medical schools are created and current medical schools expand class size. The authors of this commentary propose an expansion of the Accreditation Council for Graduate Medical Education-approved general surgery categorical resident positions as the necessary first step in addressing the current and projected shortage of general surgeons. Before this expansion of general surgery residencies can occur, impediments such as the availability of residency spots for both U.S. and international medical graduates, the availability of educational opportunities for residents in teaching hospitals, and inadequate financial resources, such as a lack of funding from the Centers for Medicare and Medicaid, must be overcome.

Transatlantic comparison of the competence of surgeons at the start of their professional career

Background

Although the objective in European Union and North American surgical residency programmes is similar—to train competent surgeons—residents' working hours are different. It was hypothesized that practice-ready surgeons with more working hours would perform significantly better than those being educated within shorter working week curricula.

Methods

At each test site, 21 practice-ready candidate surgeons were recruited. Twenty qualified Canadian and 19 qualified Dutch surgeons served as examiners. At both sites, three validated outcome instruments assessing multiple aspects of surgical competency were used.

Results

No significant differences were found in performance on the integrative and cognitive examination (Comprehensive Integrative Puzzle) or the technical skills test (Objective Structured Assessment of Technical Skill; OSATS). A significant difference in outcome was observed only on the Patient Assessment and Management Examination, which focuses on skills needed to manage patients with complex problems (P &lt; 0·001). A significant interaction was observed between examiner and candidate origins for both task-specific OSATS checklist (P = 0·001) and OSATS global rating scale (P &lt; 0·001) scores.

Conclusion

Canadian residents, serving many more working hours, perform equivalently to Dutch residents when assessed on technical skills and cognitive knowledge, but outperformed Dutch residents in skills for patient management. Secondary analyses suggested that cultural differences influence the assessment process significantly.

Restricted duty hours for surgeons and impact on residents quality of life, education, and patient care: a literature review

Background

Work-hour limitations have been implemented by the Accreditation Council for Graduate Medical Education (ACGME) in July 2003 in order to minimize fatigue related medical adverse events. The effects of this regulation are still under intense debate. In this literature review, data of effects of limited work-hours on the quality of life, surgical education, and patient care was summarized, focusing on surgical subspecialities.

Methods

Studies that assessed the effects of the work-hour regulation published following the implementation of ACGME guidelines (2003) were searched using PubMed database. The following search modules were selected: work-hours, 80-hour work week, quality of life, work satisfaction, surgical education, residency training, patient care, continuity of care. Publications were included if they were completed in the United States and covered the subject of our review. Manuscrips were analysed to identify authors, year of publication, type of study, number of participants, and the main outcomes.

Review Findings

Twenty-one articles met the inclusion criteria. Studies demonstrate that the residents quality of life has improved. The effects on surgical education are still unclear due to inconsistency in studies. Furthermore, according to several objective studies there were no changes in mortality and morbidity following the implementation.

Conclusion

Further studies are necessary addressing the effects of surgical education and studying the objective methods to assess the technical skill and procedural competence of surgeons. In addition, patient surveys analysing their satisfaction and concerns can contribute to recent discussion, as well.

Outpatient surgery centers draw cases away from hospitals, impact resident training volume

PURPOSE

Across the United States, ambulatory surgery centers (ASCs) are increasing in both number and surgical volume. This trend has been the focus of debate regarding reimbursement and patient safety, as well as surgical productivity and efficiency. However, the impact on surgical resident training caused by this shift toward outpatient surgery in nonhospital settings has not been studied. We reviewed data reported by our hospital and by local surgery centers as well as the case logs of the surgical residents at our institution to determine whether a negative effect on resident case volume has occurred.

METHODS

We conducted a retrospective review of our PGY-1 through PGY-3 level surgical residents' case logs for 3 consecutive academic years, from July 2004 through June 2007. We evaluated a group of common outpatient procedures that are now also being performed in stand-alone surgical centers in our area, such as breast biopsies, incision and drainage, hernia repair, colonoscopy, and esophagogastroduodenoscopy (EGD). The data were tallied by academic year and compared over time. In addition, we analyzed data reported to state agencies by our hospital and local surgery centers over the last 6 calendar years for any trends in case volume. By evaluating 2 different independent data sets for the same endpoint, we could evaluate our hypothesis twice.

RESULTS

When evaluating state-reported data for the defined cases, a significant decrease was observed in the total number of cases performed at Easton Hospital, Easton, Pennsylvania, each year between 2003 and 2006 (p < 0.0001). When reported cases by procedure category for 2003 versus 2005 only (because of incomplete data from ASCs in 2004 and 2006), a significant decrease was observed as well for certain specific procedures as follows: colonoscopy (p < 0.0001), inguinal/femoral hernia (p = 0.04), excision of skin lesion (p = 0.0022), and incision/drainage (p < 0.0001). When comparing resident reported data, significant decreases were observed in the number of hemorrhoidectomies, breast biopsies, skin grafts, carpal tunnel releases, and excision of skin lesions performed by residents during each academic year from July 2004 to June 2007.

CONCLUSIONS

Our residents historically have gained all of their outpatient surgery experience from procedures performed at our home institution. With the recent surge of stand-alone surgical centers, many outpatient procedures are being performed outside of the hospital in centers where our residents do not rotate. Although current residents in our program are performing enough cases to fulfill the ACGME required minimums, the number of cases is significantly decreased because of cases performed by stand-alone surgical centers.

The impact of work hour restrictions on surgical resident education

OBJECTIVE

Resident work-hour restrictions were instituted in July 2003 based on ACGME mandates. The American Board of Surgery In-Training Examination (ABSITE), American Board of Surgery Qualifying Examination (ABSQE), and operative volume traditionally have been measures of surgical resident education and competency. The objective of this study was to determine the effect of reduced work hours on resident standardized test scores and operative volume at our institution.

DESIGN

We reviewed ABSITE scores, ABSQE scores, and operative logs from 1997 to 2005 of all general surgery residents. Linear mixed-effects models were fitted for each component ABSITE score (total, basic science, and clinical management), and they were compared using a chi-squared likelihood ratio. Operative logs of graduating residents were compared before and after the work restrictions and were evaluated for association with ABSITE score. p-values less than 0.05 were considered significant.

RESULTS

The program was compliant with ACGME mandates within 6 months of institution. ABSITE scores improved significantly after the restriction of work hours in both basic science (p = 0.003) and total score (p = 0.008). Clinical management scores were not affected. The number of major cases recorded by graduating residents did not change. A positive correlation was found between number of cases performed during residency and clinical management ABSITE scores (p = 0.045). ABSQE scores were not impacted by operative volume during residency.

CONCLUSIONS

ABSITE scores improved significantly after the restriction of resident work hours. Resident operative experience was not affected. An unexpected consequence of work-hour restrictions may be an improvement in surgical resident education.

ACGME duty-hour restrictions decrease resident operative volume: a 5-year comparison at an ACGME-accredited university general surgery residency

OBJECTIVE

We compared the operative experience of chief residents at the Michigan State University Integrated Residency Program in General Surgery before and after duty-hour restrictions mandated by the Accreditation Council for Graduate Medical Education.

SUMMARY BACKGROUND DATA

Conflicting evidence exists regarding the influence of duty-hour restrictions upon resident operative experience.

METHODS

Resident self-reported operative experience submitted to the Residency Review Committee (RRC) for Surgery was tabulated. To control for a possible overall decrease in surgical procedures, for example, a decrease in referrals to the institution, the departmental database of surgical billings that is maintained independently from resident operative experience data also was reviewed.

RESULTS

An overall decrease of nearly 20% occurred in resident operative volume after promulgation of duty-hour restrictions. All residents met minimum RRC operative experience requirements. Over the same period, no decrease was found in the number surgical procedures performed by the department.

CONCLUSIONS

Our data suggest that restriction of resident duty hours is associated with a significant decrease in operative experience.

Current Status and Future Perspective of General Surgical Trainees in the Netherlands

BACKGROUND

The opinions of general surgical trainees about their current training program and their future career plans are important because such information can inform any redesign of surgical training programs as well as future surgical manpower planning.

METHODS

A structured questionnaire was sent to 392 general surgical trainees in the Netherlands in 2005.

RESULTS

A total of 239 (61%) questionnaires were returned by 66 (28%) women and 173 (72%) men, mean age 31.3 years. On average, trainees worked in the hospital 55 hours per week (range: 22-80 h). The mean number of operative cases performed per year was 195 (range 35-450), and this had been stable since the year 2000. The quality of the supervision by staff surgeons was rated satisfactory. The vast majority of the trainees are also satisfied with the current single year of differentiation/specialized training into one of the subspecialties, although most trainees (83%) would like to enroll in a fellowship before taking a job as a consultant. There was also a desire to take maternity/paternity leave during training. Both male and female trainees expressed the wish to work an average of 52 hours per week as a consultant, and they want these hours to occur in 4.1 days of work per week.

CONCLUSIONS

Dutch general surgery trainees are satisfied with their training. They expressed a strong wish for specialization during and after their training. All trainees favored reduced working hours and days of work per week as fully qualified surgeons in the future.

Implementation and evaluation of a new surgical residency model

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) duty-hour requirements prompted program directors to rethink the organizational structure of their residency programs. Many surgical educators have expressed concerns that duty-hour restrictions would negatively affect quality of resident education. This article summarizes evaluation research results collected to study the impact of our reengineered residency program designed to preserve important educational activities while meeting duty-hour accreditation requirements.

STUDY DESIGN

The traditional residency structure was redesigned to include a mixture of apprenticeship, small team, and night-float models. Impact evaluation data were collected using operative case logs, standardized test scores, quality assurance data, resident perception surveys, a faculty survey, and process evaluation measures.

RESULTS

PGY1s and PGY2s enjoyed a substantial increase in operative cases. Operative cases increased overall and no resident has failed to meet ACGME volume or distribution requirements. American Board of Surgery In-Training Examination performance improved for PGY1s and PGY2s. Patient outcomes measures, including monthly mortality and number of and charges for admissions, showed no changes. Anonymously completed rotation evaluation forms showed stable or improved resident perceptions of case load, continuity, operating room teaching, appropriate level of faculty involvement and supervision, encouragement to attend conferences, and general assessment of the learning environment. A quality-of-life survey completed by residents before and after implementation of the new program structure showed substantial improvements. Faculty surveys showed perceived increases in work hours and job dissatisfaction. New physician assistant and nurse positions directly attributed to duty-hour restrictions amounted to about 0.2 full-time equivalent per resident.

CONCLUSIONS

Duty-hour restrictions produce new challenges and might require additional resources but need not cause a deterioration of surgical residents' educational experience.

Measuring the attitudes and impact of the eighty-hour workweek rules on orthopaedic surgery residents

BACKGROUND

The literature on graduate medical education contains anecdotal reports of some effects of the new eighty-hour workweek on the attitudes and performance of residents. However, there are relatively few studies detailing the attitudes of large numbers of residents in a particular surgical specialty toward the new requirements.

METHODS

Between July and November 2004, a survey created by the Academic Advocacy Committee of the American Academy of Orthopaedic Surgeons was distributed by mail, fax, and e-mail to a total of 4207 orthopaedic residents at the postgraduate year-1 through year-6 levels of training. The survey responses were tabulated electronically, and the results were recorded.

RESULTS

The survey response rate was 13.2% (554 residents). Sixty-eight percent (337) of the 495 respondents whose postgraduate-year level was known were at the postgraduate year-4 level or higher. Attitudes concerning the duty rules were mixed. Twenty-three percent of the 554 respondents thought that eighty hours constituted an appropriate number of duty hours per week; 41% believed that eighty hours were too many, and 34% thought that eighty hours were not sufficient. Thirty-three percent of the respondents had worked greater than eighty hours during at least a single one-week period since the new rules were implemented; this occurred more commonly among the postgraduate year-3 and more junior residents. Orthopaedic trauma residents had the most difficulty adhering to the new duty-hour restrictions. Eighty-two percent of the respondents indicated that their residency programs have been forced to make changes to their call schedules or to hire ancillary staff to address the rules. The use of physician assistants, night-float systems, and so-called home-call assignments were the most common strategies used to achieve compliance.

CONCLUSION

Resident attitudes toward the work rules are mixed. The rules have forced residency programs to restructure. Junior residents have more favorable attitudes toward the new standards than do senior residents. Self-reporting of duty hours is the most common method of monitoring in orthopaedic training programs. Such systems allow ample opportunity for inaccuracies in the measurement of hours worked. Although residents report an improved quality of life as a result of these new rules, the attitude that the quality of training is diminished persists.

The effect of the EWTD on training in general surgery: an analysis of electronic logbook records

The introduction of time-limited surgical training in the UK in 1994 following the Calman report raised concerns over the hands-on experience of trainees, heightened by the hours reduction demanded by the New Deal. From 1994, junior doctors' on-duty hours of work for hard-pressed posts were targeted to a limit of 56 hours but SpRs were allowed a voluntary extension from 73 on-duty hours to a maximum of 83 hours per week. By 1995 concern was being expressed at the reduction in training time and continuity of patient care and although calls for more targeted training were made, evidence of a negative impact on training has continued to surface.

The educational impact of ACGME limits on resident and fellow duty hours: a pre-post survey study

PURPOSE

To assess the educational impact of Accreditation Council for Graduate Medical Education resident work-hour limits implemented in July 2003.

METHOD

All trainees in all 76 accredited programs at two large teaching hospitals were surveyed between May and June 2003 (before work-hour reductions) and then between May and June 2004 (after work-hour reductions) about hours, education, and fatigue. Based on changes in weekly duty hours, 13 programs experiencing substantial reduction in hours were classified into a reduced-hours group. Differences in assessments of educational endpoints before and after policy implementation by trainees in the reduced-hours group were compared with those in other programs to control for potential temporal trends, using two-way ANOVA with interaction.

RESULTS

The number of respondents was 1,770 (60% response rate). The reduced-hours group reported a significant decrease in time spent directly caring for patients (from 48.5 to 42.3 mean h/wk, P = 0.03), but the volume of important clinical experiences, including procedures, was preserved, as was the sense of clinical preparedness. On 22 questions related to educational quality and adequacy, only three differences in differences were significant, with the reduced-hours group reporting a relative increase in opportunities for research, decrease in quality of faculty teaching, and decrease in educational satisfaction. The percentage of trainees reporting frequent negative effects of fatigue dropped more in the reduced-hours programs than in the other programs (P < 0.05).

CONCLUSION

This study shows that it may be possible to reduce residents' hours--and the perceived adverse impact of fatigue--while generally preserving the self-assessed quality, quantity, and outcomes of graduate medical education.

Internal medicine residents' clinical and didactic experiences after work hour regulation: a survey of chief residents

BACKGROUND

Work hour regulations for house staff were intended in part to improve resident clinical and educational performance.

OBJECTIVE

To characterize the effect of work hour regulation on internal medicine resident inpatient clinical experience and didactic education.

DESIGN

Cross-sectional mail survey.

PARTICIPANTS

Chief residents at all accredited U.S. internal medicine residency programs outside New York.

MEASUREMENTS AND MAIN RESULTS

The response rate was 62% (202/324). Most programs (72%) reported no change in average patient load per intern after work hour regulation. Many programs (48%) redistributed house staff admissions through the call cycle. The number of admissions per intern on long call (the day interns have the most admitting responsibility) decreased in 31% of programs, and the number of admissions on other days increased in 21% of programs. Residents on outpatient rotations were given new ward responsibilities in 36% of programs. Third-year resident ward and float time increased in 34% of programs, while third-year elective time decreased in 22% of programs. The mean weekly hours allotted to educational activities did not change significantly (12.7 vs 12.4, P = .12), but 56% of programs reported a decrease in intern attendance at educational activities.

CONCLUSIONS

In response to work hour regulation, many internal medicine programs redistributed rather than reduced residents' inpatient clinical experience. Hours allotted to educational activities did not change; however, most programs saw a decrease in intern attendance at conferences, and many reduced third-year elective time.

Myths and Realities of the 80-Hour Work Week

BACKGROUND

Myths are so ingrained into cultural traditions that emotion frequently overshadows a rational evaluation of the facts. The reduction in resident work hours has resulted in the formation of several myths. The purpose of this review is to examine the published data on resident work hours to separate out myth from reality.

METHODS

An electronic database was searched for publications related to resident training, work-hours, continuity of care, sleep deprivation, quality of life, patient safety, clinical/operative experience, faculty work hours, and surgical education.

RESULTS

Sleep deprivation has been shown to be harmful, and residents played a role in advocating for work-hour limits. Surgical residents have seen a less dramatic improvement in quality of life compared with other disciplines. Work-hour reductions have decreased participation in clinic but have not resulted in a significant decline in clinical or operative exposure. Limiting resident work hours will unlikely result in a decrease health-care cost. Reduction in resident work hours has not resulted in an improvement or deterioration in patient outcome. Reduction of work hours has not increased faculty work hours nor made surgery a more attractive career choice.

CONCLUSIONS

Despite strongly held opinions, resident work-hour reduction has resulted in little significant change in lifestyle, clinical exposure, patient well-being, faculty work hours, or medical student recruitment.

Pediatric surgery fellowship compliance to the 80-hour work week

OBJECTIVE

The goal of this study was to determine the compliance of pediatric surgery fellowships with Accreditation Council for Graduate Medical Education (ACGME) duty hour restrictions while confronting a reduced resident workforce.

MATERIALS AND METHODS

An evaluation of training programs was performed by surveying pediatric surgery fellows on aspects of work hours, ACGME guideline compliance, operative case volume, employment of physician extenders, and didactic education.

RESULTS

A 74% survey response rate was achieved. Of the respondents, 95% felt fully aware of ACGME guidelines. Although 95% of programs had mechanisms for compliance in place, only 45% of fellows felt compliant. Median work hours were 80 to 90 hours per week. Although subordinate residents were felt to obtain better compliance (>86%), only 69% of fellows perceived greater service commitment as a result. No impact on volume of operative cases was perceived. Of the programs, 89% employed physician extenders and 55% used additional fellows, but no overall effect on fellow work hours was evident. Fellows did not identify an improvement in the quality of clinical fellowships with guideline implementation.

CONCLUSIONS

A minority of fellows comply with ACGME guidelines. Vigilance of duty hour tracking correlates to better compliance. A shift of patient care to fellows is perceived. Use of support personnel did not significantly aid compliance.