Implementation and evaluation of a new surgical residency model

Intern Perceptions and Participation in the Operating Room

OBJECTIVE

ACGME work hour restrictions and decreasing resident case volumes have led to concern regarding competence of surgical residency graduates. Early operative experience is an important component of surgical education, providing a foundation for further learning. Intern year represents an opportunity for increased exposure. We sought to examine factors impacting intern perceptions and participation in the operating room.

METHODS

This cross-sectional retrospective study evaluated the experience of interns from June 2019 through June 2020. Data was collected from nursing operative case logs, self-reported ACGME intern case logs, and an intern survey from the 2019 to 2020 academic year for 3 surgical services at a large academic institution. The primary endpoint was intern presence in operative cases and perceived experience.

SETTING

University of California, Davis Medical Center, a large academic training institution and tertiary referral center located in Sacramento, California.

PARTICIPANTS

A total of 31 interns comprised the 2019 to 2020 training cohort, including preliminary, categorical general surgery, and integrated subspecialty residents classified as intern by the institution, regardless of postgraduate training year.

RESULTS

Interns were present in 945 (46%) of 2054 operative cases. Multivariable analysis indicated the presence of an APP (OR 1.68, 95% C.I. 1.34-2.10, p = 0.00) and a female attending (OR 1.30, 95% C.I. 1.07-1.58, p = 0.01) increased the likelihood of intern participation, while presence of an upper level resident decreased the likelihood (OR 0.35, 95% C.I. 0.22-0.57, p = 0.00). Interns participated in more cases later in the year compared to earlier (43% vs 59%, Z = 4.72, p = < 0.001). Surveys demonstrated participation was associated with encouragement by faculty and senior residents and a positive learning environment. Competing floor and clinic responsibilities negatively impacted participation (p < 0.001).

CONCLUSIONS

Intern operative experience can be robust in the setting of ACGME work hour guidelines. Identified factors represent possible areas for improvement in service organization.

Comparison of Operative Experiences of PGY-1 and PGY-2 General Surgery Residents During Night-Float vs. 24-Hour Call Systems

OBJECTIVE

We aimed to specifically compare the impact of a night-float system vs. a 24-hour call system on the number and types of cases performed by PGY-1 and PGY-2 general surgery residents to determine if both of these schedules could meet the ACGME first two-year 250 case minimum requirement, and if so, which schedule provided the best operative experience for PGY-1 and PGY-2 residents.

DESIGN

This is a retrospective review of call schedules and operative case logs of PGY-1 and PGY-2 general surgery residents. Residents were separated into two groups based on type of call schedule: 24-hour vs. night-float. The case logs of PGY-1 and PGY-2 residents were obtained from the ACGME Case Log System and data analysis was performed between the two groups.

SETTING

This study was performed at a general surgery residency at a hybrid academic center.

PARTICIPANTS

Forty-three residents met inclusion criteria. Twenty-three were part of the night-float system and 20 were part of the 24-hour call system.

RESULTS

Total cases and major cases for PGY-1 and PGY-2 years were compared between the two groups. The 24-hour call group had a significantly higher total number of cases than the night-float group (646.0 ± 181.5 vs. 504.8 ±148.9, p = 0.008). Major cases were also significantly higher in the 24-hour call group than the night-float group (418.5 ± 99.6 vs. 355 ± 99.5, p = 0.043).

CONCLUSIONS

Both the 24-hour call and night-float systems were able to meet the ACGME first two year 250 case minimum requirement as well as follow work-hour guidelines. The 24-hour call system was associated with PGY-1 and PGY-2 residents having a better operative experience than the night-float system.

Finding the Balance: General Surgery Resident Versus Fellow Training and Exposure in Hepatobiliary and Pancreatic Surgery

BACKGROUND

Institutions training both General Surgery (GS) residents and Hepato-Pancreatico-Biliary (HPB) fellows must strive for adequate case volumes for each trainee cohort.

METHODS

Six academic years of graduating ACGME Residency and HPB Fellowship Council case logs (July 2011-June 2017) and institutional administrative faculty billing data were examined at a single high-volume center with a formal HPB Surgical Division with both GS Residency and HPB Surgery Fellowship trainees.

RESULTS

During the 6-year period, 7482 operations were performed by HPB faculty (5.5 total full-time equivalent (FTE)) and included 2419 major liver, 375 major biliary, and 1591 major pancreas cases. Residents/fellows performed 1102 (50%)/1101 (50%) of all major liver operations, 165 (49.7%)/163 (50.3%) major biliary operations, and 843 (59.2%)/581 (40.8%) major pancreas operations, with significantly different case mix of pancreas for resident versus fellow, p < 0.0001. The overall relative proportion of total HPB cases performed by residents versus fellows was 53%/47%, respectively, and this was stable over time, with no significant decrease in resident exposure/cases with dedicated HPB fellowship.

CONCLUSIONS

Our experience in training both GS residents and HPB fellows with a formal HPB Surgical Division suggests that a high volume HPB Division allows for more than adequate exposure for both groups of trainees.

Qualities and Methods of Highly Effective Surgical Educators: A Grounded Theory Model

OBJECTIVE

To identify personal qualities and teaching methods of highly effective surgical educators using a novel research design.

DESIGN

In this qualitative study, surgical residents were sent an electronic survey soliciting nominations for faculty perceived as highly effective surgical educators. In-depth, semistructured interviews were conducted with surgeons receiving the most nominations. Grounded theory methodology identified themes for analysis.

SETTING

General, vascular, and plastic surgery residents and faculty at the University of Pennsylvania Health System.

PARTICIPANTS

A total of 77 surgical residents were surveyed. Data saturation occurred after 12 semistructured interviews with attending surgeons, corresponding to the top 15% of faculty.

RESULTS

Interviewees described both personal characteristics and specific teaching approaches that facilitated successful learning. These included providing exceptional surgical education as a mission, a strong influence from past mentors and role models, a love for the profession, and a low rate of self-professed burnout. Desirable teaching methods included promoting a culture of psychological safety (the perceived ability to take interpersonal risks within one's environment), progressive autonomy, accountability of trainees, and individualized teaching for the learner. Interviewees saw education as inseparable from clinical duties, and all surgeons believed providing exceptional patient care was the foundation of effective surgical teaching. The derived themes suggested that educators prefer "cognitive-based" approaches, focusing on learning processes rather than specific outcomes.

CONCLUSIONS

This study identified characteristics and educational styles of highly effective educators in a cohort of academic surgeons. This framework may inform the development of educational programs for residents and faculty in effective teaching methods.

Validation of a clinical rotation evaluation for physician assistant students

BACKGROUND

We conducted a prospective validation study to develop a physician assistant (PA) clinical rotation evaluation (PACRE) instrument. The specific aims of this study were to 1) develop a tool to evaluate PA clinical rotations, and 2) explore associations between validated rotation evaluation scores and characteristics of the students and rotations.

METHODS

The PACRE was administered to rotating PA students at our institution in 2016. Factor analysis, internal consistency reliability, and associations between PACRE scores and student or rotation characteristics were determined.

RESULTS

Of 206 PACRE instruments sent, 124 were returned (60.2% response). Factor analysis supported a unidimensional model with a mean (SD) score of 4.31 (0.57) on a 5-point scale. Internal consistency reliability was excellent (Cronbach α=0.95). PACRE scores were associated with students' gender (P = .01) and rotation specialty (P = .006) and correlated with students' perception of being prepared (r = 0.32; P < .001) and value of the rotation (r = 0.57; P < .001).

CONCLUSIONS

This is the first validated instrument to evaluate PA rotation experiences. Application of the PACRE questionnaire could inform rotation directors about ways to improve clinical experiences. The findings of this study suggest that PA students must be adequately prepared to have a successful experience on their rotations. PA programs should consider offering transition courses like those offered in many medical schools to prepare their students for clinical experiences. Future research should explore whether additional rotation characteristics and educational outcomes are associated with PACRE scores.

Age and sex of surgeons and mortality of older surgical patients: observational study

OBJECTIVE

To investigate whether patients' mortality differs according to the age and sex of surgeons.

DESIGN

Observational study.

SETTING

US acute care hospitals.

PARTICIPANTS

100% of Medicare fee-for-service beneficiaries aged 65-99 years who underwent one of 20 major non-elective surgeries between 2011 and 2014.

MAIN OUTCOME MEASURE

Operative mortality rate of patients, defined as death during hospital admission or within 30 days of the operative procedure, after adjustment for patients' and surgeons' characteristics and indicator variables for hospitals.

RESULTS

892 187 patients who were treated by 45 826 surgeons were included. Patients' mortality was lower for older surgeons than for younger surgeons: the adjusted operative mortality rates were 6.6% (95% confidence interval 6.5% to 6.7%), 6.5% (6.4% to 6.6%), 6.4% (6.3% to 6.5%), and 6.3% (6.2% to 6.5%) for surgeons aged under 40 years, 40-49 years, 50-59 years, and 60 years or over, respectively (P for trend=0.001). There was no evidence that adjusted operative mortality differed between patients treated by female versus male surgeons (adjusted mortality 6.3% for female surgeons versus 6.5% for male surgeons; adjusted odds ratio 0.97, 95% confidence interval 0.93 to 1.01). After stratification by sex of surgeon, patients' mortality declined with age of surgeon for both male and female surgeons (except for female surgeons aged 60 or older); female surgeons in their 50s had the lowest operative mortality.

CONCLUSION

Using national data on Medicare beneficiaries in the US, this study found that patients treated by older surgeons had lower mortality than patients treated by younger surgeons. There was no evidence that operative mortality differed between male and female surgeons.

Effect of Process Changes in Surgical Training on Quantitative Outcomes From Surgery Residency Programs

OBJECTIVES

The purpose of this article is to review the literature on process changes in surgical training programs and to evaluate their effect on the Accreditation Council of Graduate Medical Education (ACGME) Core Competencies, American Board of Surgery In-Training Examination (ABSITE) scores, and American Board of Surgery (ABS) certification.

DESIGN

A literature search was obtained from MEDLINE via PubMed.gov, ScienceDirect.com, Google Scholar on all peer-reviewed studies published since 2003 using the following search queries: surgery residency training, surgical education, competency-based surgical education, ACGME core competencies, ABSITE scores, and ABS pass rate.

RESULTS

Our initial search list included 990 articles on surgery residency training models, 539 on competency-based surgical education, 78 on ABSITE scores, and 33 on ABS pass rate. Overall, 31 articles met inclusion criteria based on their effect on ACGME Core Competencies, ABSITE scores, and ABS certification. Systematic review showed that 5/31, 19/31, and 6/31 articles on process changes in surgical training programs had a positive effect on patient care, medical knowledge, and ABSITE scores, respectively. ABS certification was not analyzed. The other ACGME core competencies were addressed in only 6 studies.

CONCLUSIONS

Several publications on process changes in surgical training programs have shown a positive effect on patient care, medical knowledge, and ABSITE scores. However, the effect on ABS certification, and other quantitative outcomes from residency programs, have not been addressed. Studies on education strategies showing evidence that residency program objectives are being achieved are still needed. This article addresses the 6 ACGME Core Competencies.

Active Learning in Medical Education: Application to the Training of Surgeons

Our article defines active learning in the context of surgical education and reviews the growing body of research on new approaches to teaching. We then discuss future perspectives and the challenges faced by the trainee and surgeon in applying active learning to surgical training. As modern surgical education faces numerous challenges, we hope our article will help surgical educators in the evaluation of curriculum development, methods of instruction, and assessment.

A Narrative Review of High-Quality Literature on the Effects of Resident Duty Hours Reforms

PURPOSE

To summarize current high-quality studies evaluating the effect and efficacy of resident duty hours reforms (DHRs) on patient safety and resident education and well-being.

METHOD

The authors searched PubMed and Medline in August 2012 and again in May 2013 for literature (1987-2013) about the effects of DHRs. They assessed the quality of articles using the Medical Education Research Study Quality Instrument (MERSQI) scoring system. They considered randomized controlled trials (RCTs), partial RCTs, and all studies with a MERSQI score ≥ 14 to be "high-quality" methodology studies.

RESULTS

A total of 72 high-quality studies met inclusion criteria. Most studies showed no change or slight improvement in mortality and complication rates after DHRs. Resident well-being was generally improved, but there was a perceived negative impact on education (knowledge acquisition, skills, and cognitive performance) following DHRs. Eleven high-quality studies assessed the impact of DHR interventions; all reported a neutral to positive impact. Seven high-quality studies assessed costs associated with DHRs and demonstrated an increase in hospital costs.

CONCLUSIONS

The results of most studies that allow enough time for DHR interventions to take effect suggest a benefit to patient safety and resident well-being, but the effect on the quality of training remains unknown. Additional methodologically sound studies on the impact of DHRs are necessary. Priorities for future research include approaches to optimizing education and clinical proficiency and studies on the effect of intervention strategies on both education and patient safety. Such studies will provide additional information to help improve duty hours policies.

A Disease-Specific Hybrid Rotation Increases Opportunities for Deliberate Practice

IMPORTANCE

Incorporating deliberate practice (DP) into residency curricula may optimize education. DP includes educationally protected time, continuous expert feedback, and a focus on a limited number of technical skills. It is strongly associated with mastery level learning.

OBJECTIVE

Determine if a multidisciplinary breast rotation (MDB) increases DP opportunities.

DESIGN

Beginning in 2010, interns completed the 4-week MDB. Three days a week were spent in surgery and surgical clinic. Half-days were in breast radiology, pathology, medical oncology, and didactics. The MDB was retrospectively compared with a traditional community rotation (TCR) and a university surgical oncology service (USOS) using rotation feedback and resident operative volume. Data are presented as mean ± standard deviation.

SETTING

Oregon Health and Science University in Portland, Oregon; an academic tertiary care general surgery residency program.

PARTICIPANTS

General surgery residents at Oregon Health and Science University participating in either the MDB, TCR or USOS.

RESULTS

A total of 31 interns rated the opportunity to perform procedures significantly higher for MDB than TCR or USOS (4.6 ± 0.6 vs 4.2 ± 0.9 and 4.1 ± 1.0, p < 0.05). MDB was rated higher than TCR on quality of faculty teaching and educational materials (4.5 ± 0.7 vs 4.1 ± 0.9 and 4.0 ± 1.2 vs 3.5 ± 1.0, p < 0.05). Interns operated more on the MDB than on the USOS and were more focused on breast resections, lymph node dissections, and port placements than on the traditional surgical rotation or USOS.

CONCLUSIONS

The MDB incorporates multidisciplinary care into a unique, disease-specific, and educationally focused rotation. It is highly rated and affords a greater opportunity for DP than either the USOS or TCR. DP is strongly associated with mastery learning and this novel rotation structure could maximize intern education in the era of limited work hours.

An Apprenticeship Rotation Teaches Chief Residents Nontechnical Skills and ACGME Core Competencies

BACKGROUND

Traditionally, surgical training has used an apprenticeship model but has more recently moved to a service-based model, with groups of residents working with groups of attending surgeons. We developed an apprenticeship rotation to enhance one-on-one interaction between chief residents and selected faculty. We hypothesized that the apprenticeship rotation would be effective for teaching nontechnical skills (NTS) and core competencies.

MATERIALS AND METHODS

An apprenticeship rotation was created at a university-based surgery residency in which each chief resident selected a single attending surgeon with whom to work exclusively with for a 4-week period. Emphasis was placed on teaching intraoperative NTS as well as the 4 difficult-to-teach Accreditation Council for Graduate Medical Education core competencies (DCC): Interpersonal and Communication Skills, Practice-Based Learning and Improvement, Professionalism, and Systems-Based Practice. Participants were surveyed afterwards about their rotation using a 5-point Likert scale. A Wilcoxon signed rank test was used to compare differences depending on data distribution.

RESULTS

All (13/13) the chief residents and 67% (8/12) faculty completed the survey. Overall, 85% of residents and 87.5% of faculty would recommend the rotation to other residents/faculty members. Both residents and faculty reported improvement in trainees' technical skills and NTS. Residents reported improvement in all 4 DCC, particularly, Practice-Based Learning and Improvement, Professionalism, and Interpersonal and Communication Skills.

CONCLUSION

The apprenticeship rotation is an effective means of teaching residents both NTS and DCC essential for independent practice. Consideration should be given to introducing this program into surgical curricula nationally.

On resident duty hour restrictions and neurosurgical training: review of the literature

Within neurosurgery, the national mandate of the 2003 duty hour restrictions (DHR) by the Accreditation Council for Graduate Medical Education (ACGME) has been controversial. Ensuring the proper education and psychological well-being of residents while fulfilling the primary purpose of patient care has generated much debate. Most medical disciplines have developed strategies that address service needs while meeting educational goals. Additionally, there are numerous studies from those disciplines; however, they are not specifically relevant to the needs of a neurosurgical residency. The recent implementation of the 2011 DHR specifically aimed at limiting interns to 16-hour duty shifts has proven controversial and challenging across the nation for neurosurgical residencies--again bringing education and service needs into conflict. In this report the current literature on DHR is reviewed, with special attention paid to neurosurgical residencies, discussing resident fatigue, technical training, and patient safety. Where appropriate, other specialty studies have been included. The authors believe that a one-size-fits-all approach to residency training mandated by the ACGME is not appropriate for the training of neurosurgical residents. In the authors' opinion, an arbitrary timeline designed to limit resident fatigue limits patient care and technical training, and has not improved patient safety.

Effect of 2011 Accreditation Council for Graduate Medical Education Duty-Hour Regulations on Objective Measures of Surgical Training

OBJECTIVE

In July 2011, new Accreditation Council for Graduate Medical Education duty-hour regulations were implemented in surgical residency programs. We examined whether differences in objective measures of surgical training exist at our institution since implementation.

DESIGN

Retrospective reviews of the American Board of Surgery In-Training Examination performance and surgical case volume were collected for 5 academic years. Data were separated into 2 groups, Period 1: July 2008 through June 2011 and Period 2: July 2011 through June 2013.

SETTING

Single-institution study conducted at the Mount Sinai Hospital, New York, NY, a tertiary-care academic center.

PARTICIPANTS

All general surgery residents, levels postgraduate year 1 through 5, from July 2008 through June 2013.

RESULTS

No significant differences in the American Board of Surgery In-Training Examination total correct score or overall test percentile were noted between periods for any levels. Intern case volume increased significantly in Period 2 (90 vs 77, p = 0.036). For chief residents graduating in Period 2, there was a significant increase in total major cases (1062 vs 945, p = 0.002) and total chief cases (305 vs 267, p = 0.02).

CONCLUSIONS

The duty-hour regulations did not negatively affect objective measures of surgical training in our program. Compliance with the Accreditation Council for Graduate Medical Education duty-hour regulations correlated with an increase in case volume. Adaptations made by our institution, such as maximizing daytime duty hours and increasing physician extenders, likely contributed to our findings.

The Changing Landscape of Surgical Education: What are Residency Education Teams and do we Need Them?

OBJECTIVES

This study aims to understand how general surgery training programs constitute their residency education team (RET), how they define the roles of RET members, and how they measure success of the team. It fundamentally asks the question, "What is a RET and do we need one?"

DESIGN AND PARTICIPANTS

Program directors, associate program directors, educators, program coordinators, and chief residents from Accreditation Council for Graduate Medical Education (ACGME) general surgery training programs were asked to anonymously complete a survey categorized into 3 sections: (1) roles and responsibilities, (2) views of his/her RET and team members, and (3) general views about RETs. All respondents provided their opinions on the importance of a RET for administering and leading a surgical residency, whom the ideal members would be, and the main outcomes of a high-functioning RET.

RESULTS

Respondents (n = 167) included 59 (35.3%) program directors, 16 (9.6%) associate program directors, 8 (4.8%) educators, 67 (40.1%) program coordinators, and 6 (3.6%) chief residents. Overall, 84.4% of respondents were a part of a RET, defined as 2 or more individuals who are responsible and accountable for oversight and conduct of the residency training program. RET respondents expressed statistically significantly and higher importance for a RET (p < 0.0001) than their non-RET counterparts.

CONCLUSIONS

This study provides a snapshot of how some associated with general surgery residencies view and value RETs. The results of this survey are preliminary and suggest a need for educators within surgery programs and ambiguity about the role of associate program director. It also suggests that a closer look at role responsibilities may be of value, especially in view of the changing landscape of surgical education. Overall, most respondents felt that a RET was important to the main outcomes of a successful residency program.

The Effects of the Addition of a Pediatric Surgery Fellow on the Operative Experience of the General Surgery Resident

Adding fellows to surgical departments with residency programs can affect resident education. Our specific aim was to evaluate the effect of adding a pediatric surgery (PS) fellow on the number of index PS cases logged by the general surgery (GS) residents. At a single institution with both PS and GS programs, we examined the number of logged cases for the fellows and residents over 10 years [5 years before (Time 1) and 5 years after (Time 2) the addition of a PS fellow]. Additionally, the procedure related relative value units (RVUs) recorded by the faculty were evaluated. The fellows averaged 752 and 703 cases during Times 1 and 2, respectively, decreasing by 49 ( P = 0.2303). The residents averaged 172 and 161 cases annually during Time 1 and Time 2, respectively, decreasing by 11 ( P = 0.7340). The total number of procedure related RVUs was 4627 and 6000 during Times 1 and 2, respectively. The number of cases logged by the PS fellows and GS residents decreased after the addition of a PS fellow; however, the decrease was not significant. Programs can reasonably add an additional PS fellow, but care should be taken especially in programs that are otherwise static in size.

Interventions that affect resident performance on the American Board of Surgery In-Training Examination: a systematic review

OBJECTIVE

To systematically review the published literature on the effectiveness of interventions intended to improve residents' American Board of Surgery In-Training Examination (ABSITE) performances.

DESIGN

A systematic review was conducted by 2 independent investigators to identify all publications that examined the effect of specific interventions on residents' ABSITE performances from 1975 to 2013.

RESULTS

Overall, 26 published articles met study criteria. Structured reading programs and setting clear expectations with mandatory remedial programs were consistently effective in improving ABSITE performance, whereas the effect of didactic teaching conferences and problem-based learning groups was mixed. There was marked heterogeneity in the usage of study designs and reporting of results.

CONCLUSIONS

Structured reading programs and mandatory remedial programs appear to be consistently effective measures that can improve residents' ABSITE performances. There is a need for improved study design and reporting in future research conducted in this field.

Length of attending-student and resident-student interactions in the inpatient medicine clerkship

PHENOMENON: Changes in the medical education milieu have led away from the apprenticeship model resulting in shorter physician-student interactions. Faculty and student feedback suggests that supervisor/student interactions may now be more cursory with increasing numbers of supervisors per student, and shorter duration of interaction. This may affect both education and student assessment.

APPROACH

We compared inpatient attending and resident daily schedules with those of 3rd- and 4th-year medical students rotating on medicine clerkships at Brigham and Women's Hospital during academic years 2009-11 to determine the number of days of overlap. We used evaluation forms to determine the extent of evaluator's self-reported knowledge of the student.

FINDINGS

We correlated the daily schedules of 199 students and 204 resident and 187 attending physicians, which resulted in 558 resident-student pairings and 680 attending-student pairings over 2 years. During a 4-week block, students averaged 3.7 attending physicians (M = 4, range = 2-7), with 49.7% supervised by 4 or more. Attending-student overlap averaged 9 days (M = 9, range = 2-23), though 40% were 7 days or less. Students overlapped with an average 3.4 residents (M = 3, range = 1-6). Resident-student overlap averaged 12 days (M = 11, range = 3-26). There were 824 student assessment forms analyzed. Resident and attending physician supervisors describing knowledge of their student as "good/average" overlapped with students for 14 and 11 days respectively compared to resident and physician supervisors who described their knowledge as "poor" (11 days, p < .01; 6 days, p < .01). Insights: On the inpatient medicine clerkship, students have multiple supervising physicians with wide variability in the period of overlap. This leads to a disrupted apprenticeship model with fragmentation of supervision and concomitant effects on assessment, feedback, role modeling, and clerkship education.

Scheduling in the context of resident duty hour reform

Fuelled by concerns about resident health and patient safety, there is a general trend in many jurisdictions toward limiting the maximum duration of consecutive work to between 14 and 16 hours. The goal of this article is to assist institutions and residency programs to make a smooth transition from the previous 24- to 36-hour call system to this new model. We will first give an overview of the main types of coverage systems and their relative merits when considering various aspects of patient care and resident pedagogy. We will then suggest a practical step-by-step approach to designing, implementing, and monitoring a scheduling system centred on clinical and educational needs in the context of resident duty hour reform. The importance of understanding the impetus for change and of assessing the need for overall workflow restructuring will be explored throughout this process. Finally, as a practical example, we will describe a large, university-based teaching hospital network's transition from a traditional call-based system to a novel schedule that incorporates the new 16-hour duty limit.

Organizational interventions in response to duty hour reforms

BACKGROUND

Changes in resident duty hours in Europe and North America have had a major impact on the internal organizational dynamics of health care organizations. This paper examines, and assesses the impact of, organizational interventions that were a direct response to these duty hour reforms.

METHODS

The academic literature was searched through the SCOPUS database using the search terms "resident duty hours" and "European Working Time Directive," together with terms related to organizational factors. The search was limited to English-language literature published between January 2003 and January 2012. Studies were included if they reported an organizational intervention and measured an organizational outcome.

RESULTS

Twenty-five articles were included from the United States (n=18), the United Kingdom (n=5), Hong Kong (n=1), and Australia (n=1). They all described single-site projects; the majority used post-intervention surveys (n=15) and audit techniques (n=4). The studies assessed organizational measures, including relationships among staff, work satisfaction, continuity of care, workflow, compliance, workload, and cost. Interventions included using new technologies to improve handovers and communications, changing staff mixes, and introducing new shift structures, all of which had varying effects on the organizational measures listed previously.

CONCLUSIONS

Little research has assessed the organizational impact of duty hour reforms; however, the literature reviewed demonstrates that many organizations are using new technologies, new personnel, and revised and innovative shift structures to compensate for reduced resident coverage and to decrease the risk of limited continuity of care. Future research in this area should focus on both micro (e.g., use of technology, shift changes, staff mix) and macro (e.g., culture, leadership support) organizational aspects to aid in our understanding of how best to respond to these duty hour reforms.

Confounding factors in using upward feedback to assess the quality of medical training: a systematic review

PURPOSE

Upward feedback is becoming more widely used in medical training as a means of quality control. Multiple biases exist, thus the accuracy of upward feedback is debatable. This study aims to identify factors that could influence upward feedback, especially in medical training.

METHODS

A systematic review using a structured search strategy was performed. Thirty-five databases were searched. Results were reviewed and relevant abstracts were shortlisted. All studies in English, both medical and non-medical literature, were included. A simple pro-forma was used initially to identify the pertinent areas of upward feedback, so that a focused pro-forma could be designed for data extraction.

RESULTS

A total of 204 articles were reviewed. Most studies on upward feedback bias were evaluative studies and only covered Kirkpatrick level 1-reaction. Most studies evaluated trainers or training, were used for formative purposes and presented quantitative data. Accountability and confidentiality were the most common overt biases, whereas method of feedback was the most commonly implied bias within articles.

CONCLUSION

Although different types of bias do exist, upward feedback does have a role in evaluating medical training. Accountability and confidentiality were the most common biases. Further research is required to evaluate which types of bias are associated with specific survey characteristics and which are potentially modifiable.

Quality and safety of minimally invasive surgery: past, present, and future

Adverse events because of medical errors are a leading cause of death in the United States (US) exceeding the mortality rates of motor vehicle accidents, breast cancer, and AIDS. Improvements can and should be made to reduce the rates of preventable surgical errors because they account for nearly half of all adverse events within hospitals. Although minimally invasive surgery (MIS) has proven patient benefits such as reduced postoperative pain and hospital stay, its operative environment imposes substantial physical and cognitive strain on the surgeon increasing the risk of error. To mitigate errors and protect patients, a multidisciplinary approach is needed to improve MIS. Clinical human factors, and biomedical engineering principles and methodologies can be used to develop and assess laparoscopic surgery instrumentation, practices, and procedures. First, the foundational understanding and the imperative to transform health care into a high-quality and safe system is discussed. Next, a generalized perspective is presented on the impact of the design and redesign of surgical technologies and processes on human performance. Finally, the future of this field and the research needed to further improve the quality and safety of MIS is discussed.

Assessing the effects of the 2003 resident duty hours reform on internal medicine board scores

PURPOSE

To determine whether the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty hours reform affected medical knowledge as reflected by written board scores for internal medicine (IM) residents.

METHOD

The authors conducted a retrospective cohort analysis of postgraduate year 1 (PGY-1) Internal Medicine residents who started training before and after the 2003 duty hour reform using a merged data set of American Board of Internal Medicine (ABIM) Board examination and the National Board of Medical Examiners (NMBE) United States Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge test scores. Specifically, using four regression models, the authors compared IM residents beginning PGY-1 training in 2000 and completing training unexposed to the 2003 duty hours reform (PGY-1 2000 cohort, n = 5,475) to PGY-1 cohorts starting in 2001 through 2005 (n = 28,008), all with some exposure to the reform.

RESULTS

The mean ABIM board score for the unexposed PGY-1 2000 cohort (n = 5,475) was 491, SD = 85. Adjusting for demographics, program, and USMLE Step 2 exam score, the mean differences (95% CI) in ABIM board scores between the PGY-1 2001, 2002, 2003, 2004 and 2005 cohorts minus the PGY-1 2000 cohort were -5.43 (-7.63, -3.23), -3.44 (-5.65, -1.24), 2.58 (0.36, 4.79), 11.10 (8.88, 13.33) and 11.28 (8.98, 13.58) points respectively. None of these differences exceeded one-fifth of an SD in ABIM board scores.

CONCLUSIONS

The duty hours reforms of 2003 did not meaningfully affect medical knowledge as measured by scores on the ABIM board examinations.

Senior residents as teaching assistants during laparoscopic cholecystectomy in the 80-hour workweek era: effect on biliary injury and overall complication rates

PURPOSE

The resident as teaching assistant (TA) in the operating room is an important role in the maturation of surgical trainees. One concern in the current 80-hour workweek era is that current senior residents (SRs) are unprepared to serve as TAs, potentially leading to higher complication rates and a significant increase in the length of operations. The aim of this study was to analyze whether SRs serving as TAs during laparoscopic cholecystectomy (LC) resulted in an adverse effect on complication rates in the 80-hour workweek era.

METHODS

A retrospective review was conducted of 1668 LC performed at 2 affiliated general surgery teaching hospitals from 2003 through 2007. Teaching hospital A was a public teaching hospital where junior residents (JR) performed the LC with a scrubbed SR as TA under faculty supervision. Teaching hospital B was a community-based affiliate hospital where the JR performed LC with only scrubbed faculty supervision. Operative case duration, JR level, patient gender/age, operative indication, final pathology, and complication data were gathered and univariate and multivariate analyses were performed.

RESULTS

Despite a higher rate of acute cholecystitis in the TA hospital, LC-associated complications occurred at similar rates with and without SR as TA. The rate of biliary injury was also the same in both hospitals. On multivariable analysis, only male gender was associated with complications (odds ratio = 1.7; p = 0.004).

CONCLUSIONS

In the 80-hour resident workweek era, SRs acting as TAs during LC is not associated with increased total complications or an increased rate of biliary injury.

The ACGME Duty Hour Standards and Board Certification Examination Performance Trends in Surgical Specialties

BACKGROUND

Duty hour limitations initiated by the Accreditation Council for Graduate Medical Education (ACGME) in 2003 could improve resident education in surgical specialties.

OBJECTIVE

The purpose of this study was to evaluate national surgical board examination performance and its relationship to the ACGME duty hour standards.

METHODS

In this retrospective cohort study, electronically published website content was evaluated for examination statistics for the 10 surgical boards in the American Board of Medical Specialties. To evaluate examination trends over time, we performed simple linear regression. We also performed interrupted time series analyses, using segmented logistic regression. The secondary analyses consisted of a χ(2) test of passing and failing examinees before and after 2003. All statistics used α  =  .05.

RESULTS

There were 8 of 10 (80%) surgical boards with examinations that met inclusion criteria and a total of 72 482 unique examination results. Of the 16 examinations evaluated (50% written, 50% oral), 13 (81%) had either significant pass rate trends on regression analyses and/or a significant pre-post pass rate surrounding the initiation of the ACGME duty hour standards in 2003 in the secondary analysis (P < .05).

CONCLUSIONS

There are both increasing examination pass rates and some downward trends in examination performance on surgical board examinations since the initiation of the ACGME duty hour standards in 2003. The etiology of these trends is unclear, but trends are important to know for individual examinees, residency training programs, and surgical boards.

The effect of reducing maximum shift lengths to 16 hours on internal medicine interns' educational opportunities

PURPOSE

To evaluate educational experiences of internal medicine interns before and after maximum shift lengths were decreased from 30 hours to 16 hours.

METHOD

The authors compared educational experiences of internal medicine interns at Vanderbilt University Medical Center before (2010; 47 interns) and after (2011; 50 interns) duty hours restrictions were implemented in July 2011. The authors compared number of inpatient encounters, breadth of concepts in notes, exposure to five common presenting problems, procedural experience, and attendance at teaching conferences.

RESULTS

Following the duty hours restrictions, interns cared for more unique patients (mean 118 versus 140 patients per intern, P = .005) and wrote more history and physicals (mean 73 versus 88, P = .005). Documentation included more total concepts after the 16-hour maximum shift implementation, with a 14% increase for history and physicals (338 versus 387, P < .001) and a 10% increase for progress notes (316 versus 349, P < .001). There was no difference in the median number of selected procedures performed (6 versus 6, P = 0.94). Attendance was higher at the weekly chief resident conference (60% versus 68% of expected attendees, P < .001) but unchanged at morning report conferences (79% versus 78%, P = .49).

CONCLUSIONS

Intern clinical exposure did not decrease after implementation of the 16-hour shift length restriction. In fact, interns saw more patients, produced more detailed notes, and attended more conferences following duty hours restrictions.

Stress training for the surgical resident

BACKGROUND

Much effort in surgical education is placed on the development of clinical judgment and technical proficiency. However, little focus is placed on the management of stress associated with surgical performance. The inability to manage stress may lead to poor patient care, attrition from residency, and surgeon burnout.

METHODS

A blinded, matched, comparison group study to evaluate the efficacy of an educational program designed to improve surgical resident performance during stressful scenarios was conducted. The experimental group (n = 11) participated in stress training sessions, whereas the control group (n = 15) did not. Both groups then completed a simulation during which stress was evaluated using objective and subjective measures, and resident performance was graded using a standardized checklist.

RESULTS

Performance checklist scores were 5% higher in the experimental group than the control group (P = .54). No change existed in anxiety state according to the State Trait Anxiety Inventory (P = .34) or in heart rate under stress (P = .17) between groups.

CONCLUSIONS

There was a trend toward improved performance scoring but no difference in anxiety levels after stress training. However, 91% of residents rated the stress training as valuable.

The influence of key clinical practices on the knowledge of first year doctors about the patients under their care

AIMS

In 2009 in the United Kingdom the 48-h working week was introduced for junior doctors. To comply with this traditional working practices have changed. This study aims to assess how much first year (FY1) doctors know about the acute surgical patients they manage and how this is influenced by changes in key working practices.

METHODS

Surgical FY1s working in NHS hospitals answered 16 clinical questions about a standard acute surgical patient under their care 48 h after admission. Scores were analysed according to how long the FY1 had been looking after the patient, whether they had clerked the patient in, attended the post take ward round (PTWR), used a handover sheet to answer the questions and had sole or shared responsibility for the patient.

RESULTS

Two hundred and seventy-four FY1s (92% response rate) from 36 hospitals were surveyed. The overall median score was 11/16 (inter-quartile range 8-13). Only 8.4% (23/274) FY1s had clerked in the patient and 58.4% (160/274) had attended the PTWR. Clerking patients and attending the PTWR resulted in significantly higher test scores compared to FY1s who did not perform these activities (p = < 0.001 and 0.001 respectively). The scores of the 67.2% who used a handover sheet were significantly lower than those who did not (p = 0.001). Having sole or shared responsibility and duration of care made no significant difference (p = 0.143 and p = 0.458 respectively)

CONCLUSIONS

The results demonstrate that junior doctors' knowledge of their patients is significantly enhanced when they have the opportunity to perform the admission clerking and attend the PTWR. Because of working hours' restrictions this is now rare. Although use of handover sheets appears to ensure that certain key facts immediately related to the current admission are passed on, it is associated with significantly poorer wider knowledge of the patient.

Trimming the fat: optimizing overall educational value by defining factors associated with overall educational value and service-to-education ratio

OBJECTIVE

The Accreditation Council for Graduate Medical Education work rules have forced programs to critically appraise the overall educational value (OEV) of rotations. Successful rotations must satisfy Residency Review Committee mandates and optimize the service-to-education ratio (SER). This study was designed to examine the relationship between the OEV and SER and identify rotation characteristics (RC) associated with both.

DESIGN, SETTING, AND PARTICIPANTS

The Division of Surgery Education at the Hospital of the University of Pennsylvania administered a survey in FY2011 to all residents detailing resident perceptions regarding OEV, SER, and other RC. Responses were linked to additional rotation data. The relationship between OEV and SER was examined before and after controlling for significant RC identified in univariate analyses. Subgroup analyses by junior (CY1-2) and senior (CY3-5) resident status were performed.

RESULTS

The survey was sent to 85 residents participating in 48 general surgery rotations, with an overall response rate of 87%. OEV was inversely proportional to SER. All RC were significant predictors of OEV in univariate models except rotation length, patient care participation and the presence of fellows. SER alone was a significant predictor of OEV (coefficient = -1.24, p < 0.001) and explained 68% of the variation in OEV. After including other RC, SER remained a significant predictor (coefficient = -1.08, p < 0.001) and the model explained 85% of the variation in OEV. In subgroup analysis, SER remained a significant predictor of OEV for junior residents (coefficient = -1.27, p = < 0.001), but not for senior residents (coefficient = -0.46, p = 0.15).

CONCLUSIONS

The SER is inversely correlated with the OEV of general surgery rotations for the aggregate group of surgical residents, but this relationship appears to be attenuated by other factors in the senior resident group. Identification of the factors that affect junior surgical residents may provide the ability to improve the SER for junior residents and allow for significant improvements in perceived OEV for the resident body as a whole.

Review article: closing the research gap at the interface of learning and clinical practice

PURPOSE

The dialogue at the interface of education and clinical practice highlights areas of critical importance to the development of new approaches for educating anesthesiologists. The purpose of this article is to examine the literature on education and acquisition of competence in three areas relevant to the interface of learning and clinical practice, with the aim to suggest a research agenda that adds to the evidence on preparing physicians for independent practice. The three areas are: 1) transitions across the continuum of education; 2) the effect of reductions in hours of clinical training on competence; and 3) efforts to incorporate the competencies and CanMEDS roles into teaching and evaluation.

PRINCIPAL FINDINGS

Fifty-six articles relevant to one or more of the themes were identified in the review, including 21 studies of transitions (in, during, and after residency education), 19 studies on the effects of duty hour limits on residents' acquisition of competence, and 16 articles that assessed competency-based teaching and assessment in anesthesiology. Overall, the findings suggested a relative paucity of scientific evidence and a need for research and the development of new scientific theory. Studies generally treated one of the themes in isolation, while in actuality they interact to produce optimal as well as suboptimal learning situations, while medical education research often is limited by small samples, brief follow-up, and threats to validity. This suggests a "research gap" where editorials and commentaries have moved ahead of an evidence base for education. Promising areas for research include preparation for care deemed important by society, work to apply knowledge about the development of expertise in other disciplines to medicine, and ways to embed the competencies in teaching and evaluation more effectively.

CONCLUSION

Closing the research gap in medical education will require clear direction for future work. The starting point, at an institution or nationally, is dialogue within the specialty to achieve consensus on some of the most pressing questions.

Strategies to accommodate resident work-hour restrictions: impact on surgical education

BACKGROUND

The introduction of duty-hour restrictions has impacted surgical training. Several strategies were introduced by training programs in response to these restrictions. The purpose of this study was to assess the various strategies employed by residency programs to comply with work-hour restrictions with respect to the impact on the quality of surgical education.

METHODS

A national survey was developed and distributed to resident members of the Resident and Associate Society of the American College of Surgeons in all accredited residency programs across North America. Questions in the survey addressed 10 separate accommodation strategies used by training programs to adhere to resident work-hour restrictions. Resident respondents completed a 5-point Likert scale rating each strategy according to its impact on surgical education (detrimental, not very helpful, neutral, somewhat helpful, and very helpful).

RESULTS

A total of 599 (9.7%) responses were received from 6186 members of the Resident Associate Society. The use of health information technology (IT), nurse practitioners, and physician assistants were most highly rated. Hiring clinical fellows, establishing nonteaching services, and shift-work scheduling were the three most poorly rated accommodations to work-hour restrictions with respect to resident education.

CONCLUSIONS

Hospital IT and nonphysician care providers were rated by residents to optimize surgical education in the current work-hour limitation environment. We infer that strategies which lead to increased efficiency and redistribution of resident workload allow surgical trainees to spend more time on activities perceived to have higher educational value.

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.

Observational study using the tools of lean six sigma to improve the efficiency of the resident rounding process

BACKGROUND

Recent focus on resident work hours has challenged residency programs to modify their curricula to meet established duty hour restrictions and fulfill their mission to develop the next generation of clinicians. Simultaneously, health care systems strive to deliver efficient, high-quality care to patients and families. The primary goal of this observational study was to use a data-driven approach to eliminate examples of waste and variation identified in resident rounding using Lean Six Sigma methodology. A secondary goal was to improve the efficiency of the rounding process, as measured by the reduction in nonvalue-added time.

METHODS

We used the "DMAIC" methodology: define, measure, analyze, improve, and control. Pediatric and family medicine residents rotating on the pediatric hospitalist team participated in the observation phase. Residents, nurses, hospitalists, and parents of patients completed surveys to gauge their attitudes toward rounds. The Mann-Whitney test was used to test for differences in the median times measured during the preimprovement and postimprovement phases, and the Student t test was used for comparison of survey data.

RESULTS AND DISCUSSION

Collaborative, family-centered rounding with elimination of the "prerounding" process, as well as standard work instructions and pacing the process to meet customer demand (takt time), were implemented. Nonvalue-added time per patient was reduced by 64% (P  =  .005). Survey data suggested that team members preferred the collaborative, family-centered approach to the traditional model of rounding.

CONCLUSIONS

Lean Six Sigma provides tools, a philosophy, and a structured, data-driven approach to address a problem. In our case this facilitated an effort to adhere to duty hour restrictions while promoting education and quality care. Such approaches will become increasingly useful as health care delivery and education continue to transform.

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.

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.

Residents' perspectives on the learning environment: data from the Accreditation Council for Graduate Medical Education resident survey

PURPOSE

Residents' assessment of their learning environment is an important element of residency accreditation and a strong predictor of resident satisfaction. The authors examined the reliability and validity of a resident/fellow survey and explored the relationship between reported duty hours noncompliance and residents' perceptions of other aspects of their learning environments.

METHOD

The Accreditation Council for Graduate Medical Education (ACGME) administered a 29-item Web-based survey in 2007 and 2008 to 91,073 residents in 5,610 programs. Aggregate data from the survey comprised indicators of substantial compliance or noncompliance. The authors examined relationships among duty hours and aspects of the educational environment, as well as the relationship of the survey results to citations from accreditation reviews.

RESULTS

The survey demonstrated a high degree of internal reliability (Cronbach alpha, 0.84). Common factor analysis revealed two factors, educational environment and resident duty hours (eigenvalues of 5.49 and 2.42, respectively). Programs having resident-identified duty hours issues were more likely than those without such issues to have received duty hours citations from residency review committees (odds ratio: 2.04; 95% CI: 1.03, 3.05).

CONCLUSIONS

The ACGME Resident/Fellow Survey is a reliable, valid, and useful tool for evaluating residency programs. There are strong relationships between duty hours noncompliance and noncompliance in other aspects of the program environment.