Resident Work Hour Restrictions: Where Are We Now?

The Demands of Surgery Residency: More Than Just Duty Hours?

INTRODUCTION

Efforts to improve surgical resident well-being could be accelerated with an improved understanding of resident job demands and resources. In this study, we sought to obtain a clearer picture of surgery resident job demands by assessing how residents distribute their time both inside and outside of the hospital. Furthermore, we aimed to elucidate residents' perceptions about current duty hour regulations.

METHODS

A cross-sectional survey was sent to 1098 surgical residents at 27 US programs. Responses regarding work hours, demographics, well-being (utilizing the physician well-being index), and perceptions of duty hours in relation to education and rest, were collected. Data were evaluated using descriptive statistics and content analysis.

RESULTS

A total of 163 residents (14.8% response rate) were included in the study. Residents reported a median total patient care hours per week of 78.0 h. Trainees spent 12.5 h on other professional activities. Greater than 40% of residents were "at risk" for depression and suicide based on physician well-being index scores. Four major themes associated with education and rest were identified: 1) duty hour definitions and reporting mechanisms do not completely reflect the amount of work residents perform, 2) quality patient care and educational opportunities do not fit neatly within the duty hour framework, 3) resident perceptions of duty hours are impacted the educational environment, and 4) long work hours and lack of adequate rest negatively affect well-being.

CONCLUSIONS

The breadth and depth of trainee job demands are not accurately captured by current duty hour reporting mechanisms, and residents do not believe that their current work hours allow for adequate rest or even completion of other clinical or academic tasks outside of the hospital. Many residents are unwell. Duty hour policies and resident well-being may be improved with a more holistic accounting of resident job demands and greater attention to the resources that residents have to offset those demands.

Inguinal Hernia Repairs on the Chief's Service: A Safe Educational Model in Resident Entrustment

OBJECTIVE

We hypothesized that a Chief Resident Service educational model provides safe care for patients compared to that received on standard academic services where rotating residents adopt the practices and preferences of their attending.

DESIGN

We retrospectively identified patients undergoing inguinal hernia repairs from July 2016 through June 2019 and matched Chief's service patients to standard academic service patients 1:1 on CPT, sex and age. We compared patient characteristics, recurrence rates, outcomes and complications.

SETTING

Tertiary care center, single institution.

PARTICIPANTS

Overall, 77 patients undergoing inguinal hernia repairs (66% open and 34% laparoscopic) on the Chief's service matched successfully to 77 standard academic service patients during the study period.

RESULTS

Age, BMI and ASA were similar between the services, but Chief's service patients were less likely to be current smokers (1.3% vs. 24.7%) and more likely to be former smokers (59.7% vs. 26.0%) than standard academic service patients (p < 0.01). Patients presenting with incarcerated hernias (5.2% vs. 9.1%), recurrent (10.4% vs. 5.2%) and bilateral hernias (19.5% vs. 10.4%) were similar between the Chief's service and standard academic services, respectively (all p > 0.05). Operative times were longer for the Chief's service for open (123 min vs. 67, p < 0.01) and laparoscopic (112 min vs. 79, p = 0.02) repairs. Recurrence rates (6.5% vs. 3.9%, p = 0.47) and complications including infection, seroma or hematoma requiring evacuation and need for reoperation were similarly low (p > 0.05) between the Chief's and standard academic services, respectively. Despite low complication rates, Chief's service patients were more likely to present to the ED post-op (14.3% vs. 1.3%; p = 0.001), but readmission rates were similarly low (2.6% vs. 0%, p = 0.09).

CONCLUSIONS

Providing general surgery chief residents with a supervised opportunity to direct, plan and provide surgical care in clinic and the operating room, as a transition to independent practice following graduation, is safe for patients presenting with inguinal hernias. Concerns about patient safety should not be a barrier to maximizing entrustment for the evaluation and operative management of select core general surgery diagnoses and operations.

The effect of trainee involvement on surgical outcomes and complications of male infertility surgical procedures

In this study, we sought to determine the effect of trainee (resident or fellow physician) involvement in male infertility surgical procedures on patient surgical outcomes and complications. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed for fertility surgical procedures from 2006 to 2012. The procedures included were as follows: epididymectomy, spermatocelectomy, varicocelectomy ± hernia repair, ejaculatory duct resection, vasovasostomy, vasoepididymostomy and 'unlisted procedure male genital system' (to capture sperm retrieval procedures). A variety of peri- and post-operative outcomes were examined. Trainee and nontrainee-involved groups were compared by Wilcoxon rank sum tests, followed by logistic regression, univariate and multivariate analyses. 924 cases were included: 309 with trainees and 615 without. The median post-graduate trainee year was 3 (range: 0-10). Patients in the trainee-involved cohort had higher rates of chronic obstructive pulmonary disease, steroid usage and black race. Mean operative time was 42.5% longer in trainee-involved cases, even after controlling for other covariates (76.2 vs. 49.5 min, p = .00). Hospital stay length was also longer in trainee-involved cases (0.41 vs. 0.35 days, p = .02). There were no differences in superficial infections (p = 1.00), deep wound infections (p = 1.00), urinary tract infections (p = .26), or reoperations (p = .23) with or without trainee involvement.

Impact of Urology Resident Involvement on intraoperative, Long-Term Oncologic and Functional Outcomes of Robotic Assisted Laparoscopic Radical Prostatectomy

OBJECTIVE

To evaluate the impact of resident involvement in robot assisted laparoscopic prostatectomy on oncologic, functional, and intraoperative outcomes, both short and long term.

METHODS

We queried our prospectively maintained database of prostate cancer patients who underwent robotic-assisted laparoscopic prostatectomy from November 20, 2007 to December 27, 2016. We analyzed cases performed by 1 surgeon on a specific day of the week when the morning case involved at least 1 resident (R) and the afternoon case involved the attending physician only (nonresident [NR]). We compared R versus NR on a number of clinical, perioperative, and oncological outcomes.

RESULTS

A total of 230 NR and 230 R cases met inclusion criteria and were included in the analysis. Over one third (36.7%) of the NR group was Gleason 4+3 (Grade Group 3) or higher, relative to 25.9% of the R group, P = .015. Median operative time (OT) was significantly longer for R versus NR (200 minutes versus 156 minutes, P<.001) as was robotic time (161 minutes versus119 minutes, P<.001). No significant differences were noted for any other measure. Median follow-up for oncological outcomes was 30 and 33.5 months for NR and R, respectively (P= .3). Median OT and median estimated blood loss were both significantly greater in later years relative to the earlier years for R (2012-2016 versus 2007-2011; P< .001 for OT; P= .041 for median estimated blood loss) but not for NR.

CONCLUSION

Neither safety nor quality is diminished by R involvement in robot assisted laparoscopic prostatectomy.

Patient-specific mental rehearsal with interactive visual aids: a path worth exploring?

Background

Surgeons of today are faced with unprecedented challenges; necessitating a novel approach to pre-operative preparation which takes into account the specific tests each case poses. In this study, we examine patient-specific mental rehearsal for pre-surgical practice and assess whether this method has an additional effect when compared to generic mental rehearsal.

Methods

Sixteen medical students were trained how to perform a simulated laparoscopic cholecystectomy (SLC). After baseline assessments, they were randomised to two equal groups and asked to complete three SLCs involving different anatomical variants. Prior to each procedure, Group A practiced mental rehearsal with the use of a pre-prepared checklist and Group B mental rehearsal with the checklist combined with virtual models matching the anatomical variations of the SLCs. The performance of the two groups was compared using simulator provided metrics and competency assessment tool (CAT) scoring by two blinded assessors.

Results

The participants performed equally well when presented with a “straight-forward” anatomy [Group A vs. Group B—time sec: 445.5 vs. 496 p = 0.64—NOM: 437 vs. 413 p = 0.88—PL cm: 1317 vs. 1059 p = 0.32—per: 0.5 vs. 0 p = 0.22—NCB: 0 vs. 0 p = 0.71—DVS: 0 vs. 0 p = 0.2]; however, Group B performed significantly better [Group A vs. B Total CAT score—Short Cystic Duct (SCD): 20.5 vs. 26.31 p = 0.02 η² = 0.32—Double cystic Artery (DA): 24.75 vs. 30.5 p = 0.03 η² = 0.28] and committed less errors (Damage to Vital Structures—DVS, SCD: 4 vs. 0 p = 0.03 η²=0.34, DA: 0 vs. 1 p = 0.02 η² = 0.22). in the cases with more challenging anatomies.

Conclusion

These results suggest that patient-specific preparation with the combination of anatomical models and mental rehearsal may increase operative quality of complex procedures.

Design-Based Comparison of Spine Surgery Simulators: Optimizing Educational Features of Surgical Simulators

BACKGROUND

Simulation-based education has made its entry into surgical residency training, particularly as an adjunct to hands-on clinical experience. However, one of the ongoing challenges to wide adoption is the capacity of simulators to incorporate educational features required for effective learning. The aim of this study was to identify strengths and limitations of spine simulators to characterize design elements that are essential in enhancing resident education.

METHODS

We performed a mixed qualitative and quantitative cohort study with a focused survey and interviews of stakeholders in spine surgery pertaining to their experiences on 3 spine simulators. Ten participants were recruited spanning all levels of training and expertise until qualitative analysis reached saturation of themes. Participants were asked to perform lumbar pedicle screw insertion on 3 simulators. Afterward, a 10-item survey was administrated and a focused interview was conducted to explore topics pertaining to the design features of the simulators.

RESULTS

Overall impressions of the simulators were positive with regards to their educational benefit, but our qualitative analysis revealed differing strengths and limitations. Main design strengths of the computer-based simulators were incorporation of procedural guidance and provision of performance feedback. The synthetic model excelled in achieving more realistic haptic feedback and incorporating use of actual surgical tools.

DISCUSSION

Stakeholders from trainees to experts acknowledge the growing role of simulation-based education in spine surgery. However, different simulation modalities have varying design elements that augment learning in distinct ways. Characterization of these design characteristics will allow for standardization of simulation curricula in spinal surgery, optimizing educational benefit.

Simulation based teaching in interventional radiology training: is it effective?

AIM

To establish the educational effectiveness of simulation teaching in interventional radiology training.

MATERIALS AND METHODS

Electronic databases (MEDLINE, ERIC, Embase, OvidSP, and Cochrane Library) were searched (January 2000 to May 2015). Studies specifically with educational outcomes conducted on radiologists were eligible. All forms of simulation in interventional training were included. Data were extracted based on the population, intervention, comparison, and outcome (PICO) model. Kirkpatrick's hierarchy was used to establish educational intervention effectiveness. The quality of studies was assessed using the Cochrane risk of bias tool.

RESULTS

Search resulted in 377 articles, of which 15 met the inclusion criteria. Thirteen of the 15 studies achieved level 2 of Kirkpatrick's hierarchy with only one reaching level 4. Statistically significant improvements in performance metrics as objective measures, demonstrating trainee competence were seen in 12/15 studies. Subjective improvements in confidence were noted in 13/15. Only one study demonstrated skills transferability and improvements in patient outcomes.

CONCLUSION

Results demonstrate the relevance of simulated training to current education models in improving trainee competence; however, this is limited to the simulated environment as there is a lack of literature investigating its predictive validity and the effect on patient outcomes. The requirement for further research in this field is highlighted. Simulation is thus currently only deemed useful as an adjunct to current training models with the potential to play an influential role in the future of the interventional radiology training curriculum.

Urology Residency Training in Italy: Results of the First National Survey

BACKGROUND

Numerous surveys have been performed to determine the competence and the confidence of residents. However, there is no data available on the condition of Italian residents in urology.

OBJECTIVE

To investigate the status of training among Italian residents in urology regarding scientific activity and surgical exposure.

DESIGN, SETTING, AND PARTICIPANTS

A web-based survey that included 445 residents from all of the 25 Italian Residency Programmes was conducted between September 2015 and November 2015.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The main outcomes were represented by scientific activity, involvement in surgical procedures, and overall satisfaction.

RESULTS AND LIMITATIONS

In total, 324 out of 445 (72.8%) residents completed the survey. Overall, 104 (32%) residents had not published any scientific manuscripts, 148 (46%) published ≤5, 38 (12%) ≤10, 26 (8%) ≤15, four (1%) ≤20, and four (1%) >20 manuscripts, respectively. We did not observe any differences when residents were stratified by sex (p=0.5). Stent positioning (45.7%), extracorporeal shock wave lithotripsy (30.9%), transurethral resection of bladder tumor (33.0%), hydrocelectomy (24.7%), varicocelectomy (17%), ureterolithotripsy (14.5%), and orchiectomy (12.3%) were the surgical procedures more frequently performed by residents. Overall, 272 residents (84%) expressed a good satisfaction for urology specialty, while 178 (54.9%) expressed a good satisfaction for their own residency programme. We observed a statistically decreased trend for good satisfaction for urology specialty according to the postgraduate year (p=0.02).

CONCLUSIONS

Italian Urology Residency Programmes feature some heavy limitations regarding scientific activity and surgical exposure. Nonetheless, satisfaction rate for urology specialty remains high. Further improvements in Residency Programmes should be made in order to align our schools to others that are actually more challenging.

PATIENT SUMMARY

In this web-based survey, Italian residents in urology showed limited scientific productivity and low involvement in surgical procedures. Satisfaction for urology specialty remains high, demonstrating continuous interest in this field of study from residents.

Impact of resident involvement in endoscopic bladder cancer surgery on pathological outcomes

OBJECTIVE

Transurethral resection of bladder tumor (TURBT) pathology specimens which lack muscle are associated with clinical upstaging and may necessitate repeat resections, potentially delaying curative treatment. This study evaluated whether resident involvement in TURBT is associated with suboptimal perioperative outcomes.

MATERIALS AND METHODS

All TURBTs performed at a Canadian healthcare institution from November 2011 to June 2014 were reviewed. Multivariable logistic regression models assessed associations between intraoperative resident involvement and TURBT muscle presence. Among high-risk patients (high grade, ≥ T1 or carcinoma in situ) who underwent cystectomy, time from TURBT to cystectomy was compared between resident and attending urologists with the log-rank test.

RESULTS

In total, 463 TURBTs were identified. In multivariable analyses, residents were less likely to obtain muscle in specimens for all TURBTs [adjusted odds ratio (aOR) 0.59, p = 0.03] and the subset of 275 high-risk TURBTs (aOR 0.41, p = 0.006). Among patients who underwent cystectomy, time to cystectomy was delayed by a median of 23 days when residents were involved in the initial high-risk TURBT compared with attending urologists only (p = 0.024).

CONCLUSIONS

In this single academic center series, intraoperative resident involvement was associated with a decreased rate of muscle presence in TURBT specimens and a prolonged time to cystectomy.

The impact of resident involvement on outcomes in orthopedic trauma: An analysis of 20,090 cases

BACKGROUND

Involvement in patient care is critical in training orthopedic surgery residents for independent practice. As the focus on outcomes and quality measures intensifies, the impact of resident intraoperative involvement on patient outcomes will be increasingly scrutinized. We sought to determine the impact of residents' intraoperative participation on 30-day post-operative outcomes in the orthopedic trauma population.

METHODS

A total of 20,090 patients from the American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2013 were identified. Patient demographics and comorbidities, surgical variables, and 30-day post-operative (wound, minor, and major) complications were collected. Chi-squared and analysis of variance statistical methods were used to compare the 30-day outcomes of patients with and without a resident's intraoperative involvement.

RESULTS

Resident involvement had no effect in the incidence of wound and minor complications among all three anatomic sites of orthopedic trauma procedures (hip, lower extremity [LE], and upper extremity [UE]). There was no statistically significant difference in the incidence of major complications in the hip and LE groups. The UE group, however, demonstrated an increase in the rate of major complications (2.60% vs. 1.89%, p = 0.046). There was no difference in mortality or readmission rates.

CONCLUSIONS

Resident involvement in orthopedic trauma cases did not significantly impact the 30-day outcomes in nearly all domains. Our findings support continued resident involvement in the care of the orthopedic trauma patient.

Work Hour Reduction: Still Room for Improvement

OBJECTIVE

The effect of resident duty hour restrictions continues to yield conflicting results on patient outcomes. Failure to rescue (FTR), or death after a major complication, has become a topic of increasing quality assessment. The aim of this study is to evaluate the effect of duty hour restrictions on in-hospital mortality, complication rates, and FTR in patients suffering traumatic injuries.

DESIGN

Data from the National Trauma Data Bank (NTDB) were retrospectively reviewed (Research Data Set 2007-2008 and version 7.2). Patients admitted to Level I or II teaching institutions were dichotomized into pre-duty hour restriction (2002-2003) and post-duty hour restriction (2007-2008) time periods. Patients who had nonsurvivable injuries (any region Abbreviated Injury Scale score = 6), died within 48 hours, or had missing data were excluded. Multivariate logistic regression was used to adjust for differences in patient characteristics and derive adjusted outcomes.

SETTING

Level I and II teaching institutions in the NTDB.

PARTICIPANTS

All patients with trauma admitted to a Level I or II teaching institution between January 1, 2002 and June 30, 2003 and between January 1, 2007 and December 31, 2008.

RESULTS

Although overall adjusted in-hospital mortality was decreased (adjusted odds ratio [AOR] = 0.7, p < 0.001) in the post-duty hour restriction era, overall complications (AOR = 2.0, p < 0.001) and FTR (AOR = 2.0, p < 0.001) were significantly higher.

CONCLUSION

Although there may be some benefit to resident duty hour restrictions, there is still room for improvement in patient care. Individual institutions should carefully review their own complication data to identify preventable systems issues, such as poor handoffs, and opportunities for increased resident supervision.

Factors and Influences That Determine the Choices of Surgery Residency Applicants

OBJECTIVE

We sought to evaluate characteristics of residency applicants selected to interview at independent general surgery programs, identify residency information resources, assess if there is perceived bias toward university or independent programs, and determine what types of programs applicants prefer.

STUDY DESIGN

An electronic survey was sent to applicants who were selected to interview at a participating independent program. Open-ended responses regarding reasons for program-type bias were submitted. Multivariable logistic regression models were estimated to identify applicant characteristics associated with program-type preference.

SETTING

Independent general surgery residency programs.

PARTICIPANTS

A total, of 1220 applicants were selected to interview at one of 33 independent programs.

RESULTS

In total, 670 surveys were completed (55% response rate). Demographics of respondents were similar to the full invited population. Median United States Medical Licensing Examination Step 1 and Step 2 scores were between 230 to 239 and 240 to 249, respectively. Most applicants reported receiving general information about surgery residency programs and specific information about independent programs from residency program websites. 34% of respondents perceived an imbalanced representation of program types, with 96% of those reporting bias toward university programs.

CONCLUSIONS

Applicants selected to interview at independent programs are competitive for general surgery training and primarily use residency program websites for information gathering. Bias is common toward university programs for a variety of perceived reasons. This information will be useful in applicant evaluation and selection, serve as a stimulus to update program websites, and challenge independent program directors to work to alleviate bias against their programs.

Impact of inpatient caseload, emergency department duties, and online learning resource on General Medicine In-Training Examination scores in Japan

Background

Both clinical workload and access to learning resource are important components of educational environment and may have effects on clinical knowledge of residents.

Methods

We conducted a survey with a clinical knowledge evaluation involving postgraduate year (PGY)-1 and -2 resident physicians at teaching hospitals offering 2-year postgraduate training programs required for residents in Japan, using the General Medicine In-Training Examination (GM-ITE). An individual-level analysis was conducted to examine the impact of the number of assigned patients and emergency department (ED) duty on the residents’ GM-ITE scores by fitting a multivariable generalized estimating equations. In hospital-level analysis, we evaluated the relationship between for the number of UpToDate reviews for each hospital and for the hospitals’ mean GM-ITE score.

Results

A total of 431 PGY-1 and 618 PGY-2 residents participated. Residents with four or five times per month of the ED duties exhibited the highest mean scores compared to those with greater or fewer ED duties. Those with largest number of inpatients in charge exhibited the highest mean scores compared to the residents with fewer inpatients in charge. Hospitals with the greater UpToDate topic viewing showed significantly greater mean score.

Conclusion

Appropriate ED workload and inpatient caseload, as well as use of evidence-based electronic resources, were associated with greater clinical knowledge of residents.

The Effect of Resident Involvement on Perioperative Outcomes in Transurethral Urologic Surgeries

OBJECTIVE

To conduct the first study of intra- and postoperative outcomes related to intraoperative resident involvement in transurethral resection procedures for benign prostatic hyperplasia and bladder cancer in a large, multi-institutional database.

DESIGN

Relying on the American College of Surgeons National Surgical Quality Improvement Program Participant User Files (2005-2012), we abstracted all cases of endoscopic prostate surgery (EPS) for benign prostatic hyperplasia and transurethral resection of bladder tumors (TURBTs). Multivariable logistic regression models were constructed to assess the effect of trainee involvement (postgraduate year [PGY] 1-2: junior, PGY 3-4: senior, PGY ≥ 5: chief or fellow) vs attending only on operative time and length of hospital stay, as well as 30-day complication, reoperation, and readmission rates.

RESULTS

In all, 5093 EPS and 3059 TURBTs for a total of 8152 transurethral resection procedures were performed during the study period for which data on resident involvement were available. In multivariable analyses, resident involvement in EPS or TURBT was associated with increased odds of prolonged operative times and hospital readmissions in 30 days independent of resident level of training. Resident involvement was not associated with overall complications or reoperation rates.

CONCLUSIONS

Resident involvement in lower urinary tract surgeries is associated with increased readmissions. Strategies to optimize resident teaching of these common urologic procedures in order to minimize possible risks to patients should be explored.

Simulation center training as a means to improve resident performance in percutaneous noncontinuous CT-guided fluoroscopic procedures with dose reduction

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of a multifaceted simulation-based resident training for CT-guided fluoroscopic procedures by measuring procedural and technical skills, radiation dose, and procedure times before and after simulation training.

SUBJECTS AND METHODS

A prospective analysis included 40 radiology residents and eight staff radiologists. Residents took an online pretest to assess baseline procedural knowledge. Second-through fourth-year residents' baseline technical skills with a procedural phantom were evaluated. First-through third-year residents then underwent formal didactic and simulation-based procedural and technical training with one of two interventional radiologists and followed the training with 1 month of supervised phantom-based practice. Thereafter, residents underwent final written and practical examinations. The practical examination included essential items from a 20-point checklist, including site and side marking, consent, time-out, and sterile technique along with a technical skills portion assessing pedal steps, radiation dose, needle redirects, and procedure time.

RESULTS

The results indicated statistically significant improvement in procedural and technical skills after simulation training. For residents, the median number of pedal steps decreased by three (p=0.001), median dose decreased by 15.4 mGy (p<0.001), median procedure time decreased by 4.0 minutes (p<0.001), median number of needle redirects decreased by 1.0 (p=0.005), and median number of 20-point checklist items successfully completed increased by three (p<0.001). The results suggest that procedural skills can be acquired and improved by simulation-based training of residents, regardless of experience.

CONCLUSION

CT simulation training decreases procedural time, decreases radiation dose, and improves resident efficiency and confidence, which may transfer to clinical practice with improved patient care and safety.

Managing and mitigating fatigue in the era of changing resident duty hours

The medical establishment is grappling with the complex issue of duty hour regulations - an issue that is a natural consequence of the numerous changes in medical culture and practice that have occurred over the course of decades. Sleep deprivation resulting from long duty hours has a recognized impact on resident health and wellness. This paper will briefly outline the evolution of the concept of well-being in residency, review the specific theme of fatigue management within that context, and describe strategies that may be used to mitigate and manage fatigue, as well as approaches that may be taken to adapt to new scheduling models such as night float. Finally, the paper will call for a change in the culture in our workplaces and among our residents and faculty to one that promotes good health and ensures that we maintain a fit and sustainable medical workforce.

The impact of resident involvement in minimally-invasive urologic oncology procedures

INTRODUCTION

Robotic and laparoscopic surgical training is an integral part of resident education in urology, yet the effect of resident involvement on outcomes of minimally-invasive urologic procedures remains largely unknown. We assess the impact of resident participation on surgical outcomes using a large multi-institutional prospective database.

METHODS

Relying on the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files (2005-2011), we abstracted the 3 most frequently performed minimally-invasive urologic oncology procedures. These included radical prostatectomy, radical nephrectomy and partial nephrectomy. Multivariable logistic regression models were constructed to assess the impact of trainee involvement (PGY 1-2: junior, PGY 3-4: senior, PGY ≥5: chief) versus attending-only on operative time, length-of-stay, 30-day complication, reoperation and readmission rates.

RESULTS

A total of 5459 minimally-invasive radical prostatectomies, 1740 minimally-invasive radical nephrectomies and 786 minimally-invasive partial nephrectomies were performed during the study period, for which data on resident surgeon involvement was available. In multivariable analyses, resident involvement was not associated with increased odds of overall complications, reoperation, or readmission rates for minimally-invasive prostatectomy, radical and partial nephrectomy. However, operative time was prolonged when residents were involved irrespective of the type of procedure. Length-of-stay was decreased with senior resident involvement in minimally-invasive partial nephrectomies (odds ratio [OR] 0.49, p = 0.04) and prostatectomies (OR 0.68, p = 0.01). The major limitations of this study include its retrospective observational design, inability to adjust for the case complexity and surgeon/hospital characteristics, and the lack of information regarding the minimally-invasive approach utilized (whether robotic or laparoscopic).

CONCLUSIONS

Resident involvement is associated with increased operative time in minimally-invasive urologic oncology procedures. However, it does not adversely affect the complication, reoperation or readmission rates, as well as length-of-stay.

Perceived effects of the 16-hour workday restriction on surgical specialties: Quebec's experience

OBJECTIVE

Quebec was the first Canadian province to implement a 16-hour workday restriction. Our aim was to assess and compare Quebec's surgical residents' and professors' perception regarding the effects on the educational environment, quality of care, and quality of life.

DESIGN

The Surgical Theater Educational Environment Measure, the Postgraduate Hospital Educational Environment Measure, quality of the medical act, and quality-of-life questionnaires were administered 6 months after the work-hour restrictions.

SETTING

Université de Montréal Surgery Department, Montréal, Québec, Canada; Université de Sherbrooke Surgery Department, Sherbrooke, Québec, Canada; Université Laval Surgery Department, Québec, Québec, Canada; and McGill University Surgery Department, Montréal, Québec, Canada.

PARTICIPANTS

Surgical residents and professors of all specialties within the 4 university surgery departments in Quebec through a voluntary web-based survey.

RESULTS

A total of 280 questionnaires were analyzed with response rates of 29.7% and 16.4% for residents and professors, respectively. Data were coded on a scale from 2 (strong improvement perception) to -2 (strong deterioration perception). The professors perceived a higher negative effect than the residents did on the educational environment, i.e., role of autonomy (-0.399 vs. -0.577, p < 0.001), teaching (-0.496 vs. -0.540, p < 0.001), social support (-0.345 vs. -0.535, p < 0.001), and surgical learning (-0.409 vs. -0.626, p < 0.001). The professors also observed a higher negative effect on patients' safety (-0.199 vs. -0.595, p = 0.003) and quality of care (-0.077 vs. -0.421, p = 0.014). The latter was even perceived as unchanged by residents (-0.077, 95% CI: -0.249 to 0.095). The residents perceived a negative effect on their quality of life, whereas the professors believed the contrary (0.500 vs -0.496, p < 0.001). More professors than residents believed residency should be prolonged (80.8% vs. 50.6%, p < 0.001).

CONCLUSIONS

Residents and professors perceive a mild negative effect on the educational environment and quality of care, whereas their perception on quality of life is opposite. The professors seem concerned about adequate training to the point of considering increasing training length.

Impact of Resident Involvement on Orthopaedic Surgery Outcomes: An Analysis of 30,628 Patients from the American College of Surgeons National Surgical Quality Improvement Program Database

BACKGROUND

Operative procedural training is a key component of orthopaedic surgery residency. The influence of intraoperative resident participation on the outcomes of surgery has not been studied extensively using large, population-based databases.

METHODS

We identified 30,628 patients who underwent orthopaedic procedures from the 2011 American College of Surgeons National Surgical Quality Improvement Program. Outcomes as measured by perioperative complications, readmission rates, and mortality within thirty days were compared for cases with and without intraoperative resident involvement.

RESULTS

Logistic regression with propensity score analysis revealed that intraoperative resident participation was associated with decreased rates of overall complications (odds ratio, 0.717 [95% confidence interval, 0.657 to 0.782]), medical complications (odds ratio, 0.723 [95% confidence interval, 0.661 to 0.790]), and mortality (odds ratio, 0.638 [95% confidence interval, 0.427 to 0.951]). Resident presence in the operating room was not predictive of wound complications (odds ratio, 0.831 [95% confidence interval, 0.656 to 1.053]), readmission (odds ratio, 0.962 [95% confidence interval, 0.830 to 1.116]), or reoperation (odds ratio, 0.938 [95% confidence interval, 0.758 to 1.161]). A second analysis by propensity score stratification into quintiles grouped by similar probability of intraoperative resident presence showed resident involvement to correlate with decreased rates of overall and medical complications in three quintiles, but increased rates of overall and medical complications in one quintile. All other outcomes were equivalent across quintiles.

CONCLUSIONS

Orthopaedic resident involvement during surgical procedures is associated with lower risk of perioperative complications and mortality in the National Surgical Quality Improvement Program database. The results support resident participation in the operative care of orthopaedic patients.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The effect of resident participation on short-term outcomes after orthopaedic surgery

BACKGROUND

The influence of resident involvement on short-term outcomes after orthopaedic surgery is mostly unknown.

QUESTIONS/PURPOSES

The purposes of our study were to examine the effects of resident involvement in surgical cases on short-term morbidity, mortality, operating time, hospital length of stay, and reoperation rate and to analyze these parameters by level of training.

METHODS

The 2005–2011 American College of Surgeons National Surgical Quality Improvement Program data set was queried using Current Procedural Terminology codes for 66,817 cases across six orthopaedic procedural domains: 28,686 primary total joint arthroplasties (TJAs), 2412 revision TJAs, 16,832 basic and 5916 advanced arthroscopies, 8221 lower extremity traumas, and 4750 spine arthrodeses (fusions). Bivariate and multivariate logistic regression and propensity scores were used to build models of risk adjustment. We compared the morbidity and mortality rates, length of operating time, hospital length of stay, and reoperation rate for cases with or without resident involvement. For cases with resident participation, we analyzed the same parameters by training level.

RESULTS

Resident participation was associated with higher morbidity in TJAs (odds ratio [OR], 1.6; range, 1.4–1.9), lower extremity trauma (OR, 1.3; range, 1.2–1.5), and fusion (OR, 1.4; range, 1.2–1.7) after adjustment. However, resident involvement was not associated with increased mortality. Operative time was greater (all p < 0.001) with resident involvement in all procedural domains. Longer hospital length of stay was associated with resident participation in lower extremity trauma (p < 0.001) and fusion cases (p = 0.003), but resident participation did not affect length of stay in other domains. Resident involvement was associated with greater 30-day reoperation rates for cases of lower extremity trauma (p = 0.041) and fusion (p < 0.001). Level of resident training did not consistently influence surgical outcomes.

CONCLUSIONS

Results of our study suggest resident involvement in surgical procedures is not associated with increased short-term major morbidity and mortality after select cases in orthopaedic surgery. Findings of longer operating times and differences in minor morbidity should lead to future initiatives to provide resident surgical skills training and improve perioperative efficiency in the academic setting.

LEVEL OF EVIDENCE

Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Handoffs in general surgery residency, an observation of intern and senior residents

BACKGROUND

Handoffs have become an area of concern as duty-hour restrictions impose an increasing number of shift changes. The objective of this study was to study handoffs in a general surgery residency and identify problems that exist in the current handoff process in preparation for a standardized implemented protocol.

METHODS

A resident researcher observed resident-to-resident handoffs for 5 surgical service teams, Monday through Friday, for the middle 2 weeks of the 3rd month of the academic year. Each handoff was observed for the presence, absence, or inconsistency of code status; anticipated problems; active problems; current baseline status; pending tests or consults; and closed-loop communication.

RESULTS

Thirty-eight residents in 2010 were observed, with a total of 52 handoffs ranging from 1 to 27 minutes in length. Five handoffs (10%) were by phone, 47 handoffs (90%) were observed in person, 10 handoffs (19%) were by senior residents, and 37 handoffs (71%) were performed by junior residents. Of the 47 in-person handoffs, code status was mentioned in 2 (4%), and 6 (12%) were given written notes. Of the 37 intern handoffs, the presence of measured criteria occurred in the following percentages: 59% for anticipated problems, 70% for active problems, 51% for current baseline status, 64% for pending tests or consults, and 81% for closed-loop communication. Of the 10 senior-level handoffs observed, all consistently included the previously mentioned criteria.

CONCLUSIONS

This study demonstrates the lack of consistency and propensity for error in unstructured handoffs among junior residents. The finding that senior-level residents exhibited consistently proficient handoffs demonstrates that handoffs are a learned skill. Therefore, teaching junior residents a structured handoff supervised by senior residents would most likely reduce the inconsistency and error-prone nature of the junior-level handoffs observed in our study.

Teaching and Assessing Colorectal Surgery Residents in the Age of ACGME Competencies: Pieces of the Whole

Educators have struggled with teaching and evaluation of the six Accreditation Council for Graduate Medical Education (ACGME) core competencies since their introduction in 1999. In addition, many authors have questioned the construct validity of the competencies. Concern has also arisen regarding the educational effects of the competencies and the subsequent limitation of resident duty hours, the combination of which have forced unprecedented changes in American graduate medical education. This article attempts to present an understanding of how these events have had direct and indirect effects on the education of residents in colon and rectal surgery, and to provide a framework for educators in colon and rectal surgery to adapt in their curricula.

Teaching and assessing procedural skills: a qualitative study

BACKGROUND

Graduating Internal Medicine residents must possess sufficient skills to perform a variety of medical procedures. Little is known about resident experiences of acquiring procedural skills proficiency, of practicing these techniques, or of being assessed on their proficiency. The purpose of this study was to qualitatively investigate resident 1) experiences of the acquisition of procedural skills and 2) perceptions of procedural skills assessment methods available to them.

METHODS

Focus groups were conducted in the weeks following an assessment of procedural skills incorporated into an objective structured clinical examination (OSCE). Using fundamental qualitative description, emergent themes were identified and analyzed.

RESULTS

Residents perceived procedural skills assessment on the OSCE as a useful formative tool for direct observation and immediate feedback. This positive reaction was regularly expressed in conjunction with a frustration with available assessment systems. Participants reported that proficiency was acquired through resident directed learning with no formal mechanism to ensure acquisition or maintenance of skills.

CONCLUSIONS

The acquisition and assessment of procedural skills in Internal Medicine programs should move toward a more structured system of teaching, deliberate practice and objective assessment. We propose that directed, self-guided learning might meet these needs.

Abolishment of 24-hour continuous medical call duty in quebec: a quality of life survey of general surgical residents following implementation of the new work-hour restrictions

BACKGROUND

The implementation of work hour restrictions across North America have resulted in decreased levels of self injury and medical errors for Residents. An arbitration ruling in Quebec has led to further curtailment of work hours beyond that proposed by the ACGME. This may threaten Resident quality of life and in turn decrease the educational quality of surgical residency training.

METHODS

We administered a quality of life questionnaire with an integrated education quality assessment tool to all General Surgery residents training at McGill 6 months after the work hour restrictions.

RESULTS

Across several strata respondents reveal a decreased sense of educational quality and quality of life.

CONCLUSIONS

The arbitration argued that work- hour restrictions would be necessary to improve quality of life for trainees and hence improve patient safety. Results from this study demonstrate the exact opposite in a large majority of respondents, who report a poorer quality of life and a self-reported inability on their part to provide continuous and safe patient care.

Part-time general surgical training in South Australia: its success and future implications (or: pinnacles, pitfalls and lessons for the future)

BACKGROUND

Flexible training options are sought by an increasing number of Australasian surgical trainees. Reasons include increased participation of women in the surgical workforce, postgraduate training and changing attitudes to family responsibilities. Despite endorsement of flexible training by the Royal Australasian College of Surgeons and Board in General Surgery, part-time (PT) training in General Surgery in Australia and New Zealand is not well established. A permanent 'stand-alone' PT training position was established at the Royal Adelaide Hospital in 2007 under the Surgical Education and Training Program. This position offered 12 months of General Surgical training on a 0.5 full-time (FT) equivalent basis with pro rata emergency and on-call commitments and was accredited for 6 months of General Surgical training. This paper reviews the PT training experience in South Australia.

METHODS

De-identified logbook data were obtained from the South Australian Regional Subcommittee of the Board in General Surgery with consent of each of the trainees. Totals of operative cases were compared against matched FT trainees working on the same unit.

RESULTS

Overall, PT trainees achieved comparable operative caseloads compared with their FT colleagues. All trainees included in this review have subsequently passed the Royal Australasian College of Surgeons Fellowship Examination in General Surgery and returned to FT workforce positions.

CONCLUSION

This paper presents two validated models of PT training. Training, resource and regulatory requirements and individual and institutional barriers to flexible training are substantial. Successful PT models offer positive and beneficial training alternatives for General Surgical trainees and contribute to workforce flexibility.

Duty hours, quality of care, and patient safety: general surgery resident perceptions

BACKGROUND

The balance between patient treatment risks and training residents to proficiency is confounded by duty-hour limits. Stricter limits have been recommended to enhance quality and safety, although supporting data are scarce.

STUDY DESIGN

A previously piloted survey was delivered with the 2010 American Board of Surgery In-Training Examination (ABSITE). First postgraduate year (PGY1) and PGY2 trainees took the Junior examination (IJE); PGY3 and above took the Senior examination (ISE). Residency type, size, and location were linked to examinees using program codes. Five survey items queried all residents about the impact of further hour limits on care quality; online test residents answered 7 more items probing medical error sources. Data were analyzed using factorial ANOVA for association with sex, PGY level, and program demographics.

RESULTS

There were 6,161 categorical surgery residents who took the ABSITE: 60% men, 60% ISE, and two-thirds in university programs. Paper (n = 5,079) and online (n = 1,082) examinees were similar. Item response rates ranged from 91% to 98%. Few (<25%) perceived that stricter hour limits would improve care quality to a large or maximal extent. IJE plus West and Northeast residents significantly more often favored fewer hours. Factors perceived as contributing to medical errors usually or always by ≥ 15% of residents were incomplete handoffs, inexperience or lack of knowledge, insufficient ancillary personnel, and excessive workload.

CONCLUSIONS

Most categorical surgery residents do not perceive that reduced duty hours will noticeably improve quality of care. Resident perceptions of causes of medical errors suggest that system changes are more likely to enhance patient safety than further hour limits.

The perspective of the vascular surgery trainee on new ACGME regulations, fatigue, resident training, and patient safety

OBJECTIVE

To assess the opinions of vascular surgery trainees on the new Accreditation Council for Graduate Medical Education (ACGME) guidelines.

METHODS

A questionnaire was developed and electronically distributed to trainee members of the Society for Vascular Surgery.

RESULTS

Of 238 eligible vascular trainees, 38 (16%) participated. Respondents were predominantly 30 to 35 years of age (47%), male (69%), in 2-year fellowship (73%), and at large academic centers (61%). Trainees report occasionally working while fatigued (63%). Fellows were more likely to report for duty while fatigued (P = .012) than integrated vascular residents. Respondents thought further work-hour restrictions would not improve patient care or training (P < .05) and may not lead to more sleep or improved quality of life. Respondents reported that duty hours should vary by specialty (81%) and allow flexibility in the last years of training (P < .05).

CONCLUSIONS

Vascular surgery trainees are concerned about further duty-hour restrictions on patient care, education, and training and fatigue mitigation has to be balanced against the need to adequately train vascular surgeons.

Are Canadian general surgery residents ready for the 80-hour work week? A nationwide survey

BACKGROUND

The purpose of this study was to describe Canadian general surgery residents' perceptions regarding potential implementation of work-hour restrictions.

METHODS

An ethics review board-approved, Web-based survey was submitted to all Canadian general surgery residency programs between April and July 2009. Questions evaluated the perceived effects of an 80-hour work week on length of training, operative exposure, learning and lifestyle. We used the Fisher exact test to compare senior and junior residents' responses.

RESULTS

Of 360 residents, 158 responded (70 seniors and 88 juniors). Among them, 79% reported working 75-100 hours per week. About 74% of seniors believed that limiting their work hours would decrease their operative exposure; 43% of juniors agreed (p < 0.001). Both seniors and juniors thought limiting their work hours would improve their lifestyle (86% v. 96%, p = 0.12). Overall, 60% of residents did not believe limiting work hours would extend the length of their training. Regarding 24-hour call, 60% of juniors thought it was hazardous to their health; 30% of seniors agreed (p = 0.001). Both senior and junior residents thought abolishing 24-hour call would decrease their operative exposure (84% v. 70%, p = 0.21). Overall, 31% of residents supported abolishing 24-hour call. About 47% of residents (41% seniors, 51%juniors, p = 0.26) agreed with the adoption of the 80-hour work week.

CONCLUSION

There is a training-level based dichotomy of opinion among general surgery residents in Canada regarding the perceived effects of work hour restrictions. Both groups have voted against abolishing 24-hour call, and neither group strongly supports the implementation of the 80-hour work week.

Analysing the operative experience of basic surgical trainees in Ireland using a web-based logbook

BACKGROUND

There is concern about the adequacy of operative exposure in surgical training programmes, in the context of changing work practices. We aimed to quantify the operative exposure of all trainees on the National Basic Surgical Training (BST) programme in Ireland and compare the results with arbitrary training targets.

METHODS

Retrospective analysis of data obtained from a web-based logbook (http://www.elogbook.org) for all general surgery and orthopaedic training posts between July 2007 and June 2009.

RESULTS

104 trainees recorded 23,918 operations between two 6-month general surgery posts. The most common general surgery operation performed was simple skin excision with trainees performing an average of 19.7 (± 9.9) over the 2-year training programme. Trainees most frequently assisted with cholecystectomy with an average of 16.0 (± 11.0) per trainee. Comparison of trainee operative experience to arbitrary training targets found that 2-38% of trainees achieved the targets for 9 emergency index operations and 24-90% of trainees achieved the targets for 8 index elective operations. 72 trainees also completed a 6-month post in orthopaedics and recorded 7,551 operations. The most common orthopaedic operation that trainees performed was removal of metal, with an average of 2.90 (± 3.27) per trainee. The most common orthopaedic operation that trainees assisted with was total hip replacement, with an average of 10.46 (± 6.21) per trainee.

CONCLUSIONS

A centralised web-based logbook provides valuable data to analyse training programme performance. Analysis of logbooks raises concerns about operative experience at junior trainee level. The provision of adequate operative exposure for trainees should be a key performance indicator for training programmes.

The Lost Opportunities for Surgical Training in the NHS

Surgery is a craft specialty based on gaining sufficient operating theatre experience. The European Working Time Directive was introduced in 1998 to protect the health and safety of employees. However, the progressive reduction in the hours available for surgical training combined with full-shift working patterns have raised fears that we will produce less experienced surgeons in the future.

Emerging ethical issues in pediatric surgery

With the rapid pace of technological advancement and changing political, social, and legal attitudes, physicians face new ethical dilemmas. For pediatric surgeons, these emerging issues affect our relationship with, and the care we provide, to our patients and their families. In this review, we explore issues related to professionalism in pediatric surgery practice, the value of apology, and the risks associated with sleep deprivation. Furthermore, we discuss how the imperative of patient safety presents an opportunity for specialty-driven effort to define standards for the surgical care of children and a responsible process for introducing surgical innovations. Finally, we remind pediatric surgeons of their ethical and professional duty to support clinical research, and advocate the acceptance of community equipoise as sufficient basis for enrolling children in clinical trials.