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Boomer LA, Nielsen JW, Lowell W, Haley K, Coffey C, Nuss KE, Nwomeh BC, Groner JI. Managing moderately injured pediatric patients without immediate surgeon presence: 10 years later. J Pediatr Surg 2015; 50:182-5. [PMID: 25598120 DOI: 10.1016/j.jpedsurg.2014.10.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 10/06/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE Beginning in 2003, the pediatric emergency medicine (PEM) physician replaced the surgeon as the team leader for all level II trauma resuscitations at a busy pediatric trauma center. The purpose was to review the outcomes 10 years after implementing this practice change. METHODS Trauma registry data for all level II activations requiring admission were extracted for the 21 months (April 1, 2001-December 31, 2002) prior to policy change (period 1, **n=627) and compared to the admitted patients from the 10 subsequent years (2003-2013; period 2, n=2694). Data included demographics, length of stay (LOS), injury severity score (ISS), readmissions, complications, and mortality. RESULTS Mean ISS scores for admitted patients during period 1 (8.5) were higher than during period 2 (7.8). During period 1, 53.6% of patients underwent abdominal CT versus 41.8% in period 2 (p<.001), and the median ED LOS was 135 versus 191 minutes in period 2. From 2000 to 2003, 91% of patients seen as level II trauma alerts were admitted compared to 56.6% of patients in period 2 (p<0.001). There were no missed abdominal injuries identified, and readmission rate was low. CONCLUSIONS We conclude that level II trauma resuscitations can be safely evaluated and managed without immediate surgeon presence. Although ED LOS increased, admission rate and CT scan usage decreased significantly without an increase in missed injuries.
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Affiliation(s)
- Laura A Boomer
- Department of Pediatric Surgery, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jason W Nielsen
- Department of Pediatric Surgery, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Wendi Lowell
- Trauma Program, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kathy Haley
- Trauma Program, Nationwide Children's Hospital, Columbus, OH, USA
| | - Carla Coffey
- Trauma Program, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kathryn E Nuss
- Department of Emergency Medicine, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Benedict C Nwomeh
- Department of Pediatric Surgery, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jonathan I Groner
- Department of Pediatric Surgery, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA.
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Theobald CN, Stover DG, Choma NN, Hathaway J, Green JK, Peterson NB, Sponsler KC, Vasilevskis EE, Kripalani S, Sergent J, Brown NJ, Denny JC. The effect of reducing maximum shift lengths to 16 hours on internal medicine interns' educational opportunities. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2013; 88:512-518. [PMID: 23425987 PMCID: PMC3638874 DOI: 10.1097/acm.0b013e318285800f] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
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.
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Affiliation(s)
- Cecelia N Theobald
- Department of Medicine, School of Medicine, Vanderbilt University, Nashville, Tennessee 37212, USA.
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Philibert I, Nasca T, Brigham T, Shapiro J. Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships? Annu Rev Med 2012; 64:467-83. [PMID: 23121182 DOI: 10.1146/annurev-med-120711-135717] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Long hours are an accepted component of resident education, yet data suggest they contribute to fatigue that may compromise patient safety. A systematic review confirms that limiting duty hours increases residents' hours of sleep and improves objective measures of alertness. Most studies of operative experience for surgical residents found no effect, and there is evidence of a limited positive effect on residents' mood. We find a mixed effect on patient safety, although problems with supervision, rather than the limits, may be responsible or contibute; evidence of reduced continuity of care and reduced continuity in residents' clinical education; and evidence that increased workload under the limits has a negative effect on patient and resident outcomes. We highlight specific areas for research and offer recommendations for national policy.
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Affiliation(s)
- Ingrid Philibert
- Accreditation Council for Graduate Medical Education, Chicago, Illinois 60654, USA.
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Jamal MH, Doi SAR, Rousseau M, Edwards M, Rao C, Barendregt JJ, Snell L, Meterissian S. Systematic review and meta-analysis of the effect of North American working hours restrictions on mortality and morbidity in surgical patients. Br J Surg 2012; 99:336-44. [DOI: 10.1002/bjs.8657] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2011] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Short duty hours, imposed by the Accreditation Council of Graduate Medical Education (ACGME) regulations, have been claimed to be associated with loss of continuity of care among surgical patients, leading to a potentially increased risk of adverse surgical outcomes. This systematic review and meta-analysis assessed the strength of associations between duty hour restrictions and morbidity and mortality of various surgical procedures.
Methods
MEDLINE, Embase, BIOSIS Previews®, the Education Resources Information Center and the Cochrane Central Register of Controlled Trials (January 2000 to September 2009) were searched, and reports screened to identify comparative studies of mortality and morbidity before and after the introduction of ACGME regulation periods. Random-effects (RE) and quality-effects (QE) meta-analyses were performed to determine the risk of morbidity or death associated with long duty hours compared with shorter duty hours. Results are presented as odds ratio (OR) with 95 per cent confidence interval.
Results
A total of 19 data sets (10 articles), including 730 648 subjects in the mortality studies and 64 346 in the morbidity studies, were analysed. Long duty hours were associated with a non-significantly increased risk of death compared with shorter duty hours (OR 1·28, 0·94 to 1·73). There was no difference in morbidity between the two groups (OR 1·03, 0·67 to 1·57). Mortality associations were generally stronger for general surgery, more recent studies and higher-quality studies. Heterogeneity was evident among the studies included.
Conclusion
The reduction in working hours has not affected patient care negatively in terms of demonstrable differences in morbidity and mortality. However, it cannot be distinguished whether this effect is actually due to a non-detrimental effect of the reduction in working hours or whether any such detriment is offset by continually improving patient care and increased surgical supervision.
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Affiliation(s)
- M H Jamal
- Department of General Surgery and Center for Medical Education, McGill University, Montreal, Quebec, Canada
- Department of General Surgery, Kuwait Medical School, Kuwait City, Kuwait
| | - S A R Doi
- School of Population Health, University of Queensland, Queensland, Australia
- Department of Endocrinology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - M Rousseau
- Department of General Surgery and Center for Medical Education, McGill University, Montreal, Quebec, Canada
| | - M Edwards
- Department of General Surgery and Center for Medical Education, McGill University, Montreal, Quebec, Canada
| | - C Rao
- School of Population Health, University of Queensland, Queensland, Australia
| | - J J Barendregt
- School of Population Health, University of Queensland, Queensland, Australia
| | - L Snell
- Department of General Surgery and Center for Medical Education, McGill University, Montreal, Quebec, Canada
| | - S Meterissian
- Department of General Surgery and Center for Medical Education, McGill University, Montreal, Quebec, Canada
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Lipsett PA. Passing in the night: a tipping point in surgical training. Surg Infect (Larchmt) 2012; 13:1-8. [PMID: 22220507 DOI: 10.1089/sur.2011.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Pamela A Lipsett
- Department of Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
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Mir HR, Cannada LK, Murray JN, Black KP, Wolf JM. Orthopaedic resident and program director opinions of resident duty hours: a national survey. J Bone Joint Surg Am 2011; 93:e1421-9. [PMID: 22159864 DOI: 10.2106/jbjs.k.00700] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The Accreditation Council for Graduate Medical Education (ACGME) established national guidelines for resident duty hours in July 2003. Following an Institute of Medicine report in December 2008, the ACGME recommended further restrictions on resident duty hours that went into effect in July 2011. We conducted a national survey to assess the opinions of orthopaedic residents and of directors of residency and fellowship programs in the U.S. regarding the 2003 and 2011 ACGME resident duty-hour regulations and the effects of these regulations on resident education and patient care. METHODS A fifteen-item questionnaire was electronically distributed by the Candidate, Resident, and Fellow Committee of the American Academy of Orthopaedic Surgeons (AAOS) to all U.S. orthopaedic residents (n = 3860) and directors of residency programs (n = 184) and fellowship programs (n = 496) between January and April 2011. Thirty-four percent (1314) of the residents and 27% (185) of the program directors completed the questionnaire. Statistical analyses were performed to detect differences between the responses of residents and program directors and between the responses of junior and senior residents. RESULTS The responses of orthopaedic residents and program directors differed significantly (p < 0.001) for fourteen of the fifteen survey items. The responses of residents and program directors were divergent for questions regarding the 2003 rules. Overall, 71% of residents thought that the eighty-hour work week was appropriate, whereas only 38% of program directors agreed (p < 0.001). Most program directors (70%) did not think that the 2003 duty-hour rules had improved patient care, whereas only 24% of residents responded in the same way (p < 0.001). The responses of residents and program directors to questions regarding the 2011 duty-hour rules were generally compatible, but the degree to which they perceived the issues was different. Only 18% of residents and 19% of program directors thought that the suggested strategic five-hour evening rest period implemented in July 2011 for on-call residents was appropriate (p > 0.05), and both groups (84% of residents and 74% of program directors) also disagreed with the limitation of intern shifts to sixteen hours (p < 0.001). Seventy percent of residents and 79% of program directors thought that the new duty-hour regulations would result in an increased number of handoffs that would be detrimental to patient care (p < 0.001). The mean responses of junior residents and senior residents differed for eight of the fifteen survey items (p < 0.001), with the responses of senior residents more closely resembling those of program directors on six of these eight questions. The mean responses and percentiles for the survey items did not differ significantly between residency directors and fellowship directors (p > 0.05). CONCLUSIONS This national survey indicated significant differences between the opinions of orthopaedic residents and program (residency and fellowship) directors regarding the 2003 ACGME resident duty-hour regulations and the effects of these regulations on resident education and patient care. However, both residents and program directors agreed that the further reductions in duty hours in the 2011 rules may be detrimental to resident education and patient care.
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Affiliation(s)
- Hassan R Mir
- Department of Orthopaedics, Vanderbilt University, Nashville, TN 37232, USA.
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Jamal MH, Rousseau MC, Hanna WC, Doi SAR, Meterissian S, Snell L. Effect of the ACGME duty hours restrictions on surgical residents and faculty: a systematic review. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2011; 86:34-42. [PMID: 21099662 DOI: 10.1097/acm.0b013e3181ffb264] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
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.
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Affiliation(s)
- Mohammad H Jamal
- General Surgery, Department of Surgery and Centre for Medical Education, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.
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Levine AC, Adusumilli J, Landrigan CP. Effects of reducing or eliminating resident work shifts over 16 hours: a systematic review. Sleep 2010; 33:1043-53. [PMID: 20815185 DOI: 10.1093/sleep/33.8.1043] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
STUDY OBJECTIVES The Institute of Medicine (IOM) has called for the elimination of resident work shifts exceeding 16 hours without sleep. We sought to comprehensively evaluate the effects of eliminating or reducing shifts over 16 hours. DESIGN AND OUTCOME MEASURES We performed a systematic review of published and unpublished studies (1950-2008) to synthesize data on all intervention studies that have reduced or eliminated U.S. residents' extended shifts. A total of 2,984 citations were identified initially, which were independently reviewed by two authors to determine their eligibility for inclusion. All outcomes relevant to quality of life, education, and safety were collected. Study quality was rated using the U.S. Preventive Services Task Force methodology. MEASUREMENTS AND RESULTS Twenty-three studies met inclusion criteria (kappa = 0.88 [95% CI, 0.77-0.94] for inclusion decisions). Following reduction or elimination of extended shifts, 8 of 8 studies measuring resident quality of life found improvements. Four of 14 studies that assessed educational outcomes found improvements, 9 found no significant changes, and one found education worsened. Seven of 11 identified statistically significant improvements in patient safety or quality of care; no studies found that safety or care quality worsened. CONCLUSIONS In a systematic review, we found that reduction or elimination of resident work shifts exceeding 16 hours did not adversely affect resident education, and was associated with improvements in patient safety and resident quality of life in most studies. Further multi-center studies are needed to substantiate these findings, and definitively measure the effects of eliminating extended shifts on patient outcomes.
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Affiliation(s)
- Adam C Levine
- Harvard Affiliated Emergency Medicine Residency, Department of Emergency Medicine, Brigham and Women's and Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
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Britt L, Sachdeva AK, Healy GB, Whalen TV, Blair PG. Resident duty hours in surgery for ensuring patient safety, providing optimum resident education and training, and promoting resident well-being: A response from the American College of Surgeons to the Report of the Institute of Medicine, “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety”. Surgery 2009; 146:398-409. [DOI: 10.1016/j.surg.2009.07.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2009] [Accepted: 07/09/2009] [Indexed: 11/27/2022]
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Pape HC, Pfeifer R. Restricted duty hours for surgeons and impact on residents quality of life, education, and patient care: a literature review. Patient Saf Surg 2009; 3:3. [PMID: 19232105 PMCID: PMC2654871 DOI: 10.1186/1754-9493-3-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Accepted: 02/20/2009] [Indexed: 12/04/2022] Open
Abstract
Background Work-hour limitations have been implemented by the Accreditation Council for Graduate Medical Education (ACGME) in July 2003 in order to minimize fatigue related medical adverse events. The effects of this regulation are still under intense debate. In this literature review, data of effects of limited work-hours on the quality of life, surgical education, and patient care was summarized, focusing on surgical subspecialities. Methods Studies that assessed the effects of the work-hour regulation published following the implementation of ACGME guidelines (2003) were searched using PubMed database. The following search modules were selected: work-hours, 80-hour work week, quality of life, work satisfaction, surgical education, residency training, patient care, continuity of care. Publications were included if they were completed in the United States and covered the subject of our review. Manuscrips were analysed to identify authors, year of publication, type of study, number of participants, and the main outcomes. Review Findings Twenty-one articles met the inclusion criteria. Studies demonstrate that the residents quality of life has improved. The effects on surgical education are still unclear due to inconsistency in studies. Furthermore, according to several objective studies there were no changes in mortality and morbidity following the implementation. Conclusion Further studies are necessary addressing the effects of surgical education and studying the objective methods to assess the technical skill and procedural competence of surgeons. In addition, patient surveys analysing their satisfaction and concerns can contribute to recent discussion, as well.
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Affiliation(s)
- Hans-Christoph Pape
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufmann Medical Building, Suite 1010, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA.
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Kairys JC, DiMuzio PJ, Crawford AG, Grabo DJ, Yeo CJ. Changes in operative case experience for general surgery residents: has the 80-hour work week decreased residents' operative experience? Adv Surg 2009; 43:73-90. [PMID: 19845170 DOI: 10.1016/j.yasu.2009.02.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- John C Kairys
- Department of Surgery, Thomas Jefferson University, 1015 Walnut Street, Room 620, Philadelphia, PA 19107, USA.
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Effects of resident work-hour restrictions on orthopaedic education and patient care. CURRENT ORTHOPAEDIC PRACTICE 2009. [DOI: 10.1097/bco.0b013e328316640a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Affiliation(s)
- Shin Kon Kim
- 60th President, the Korean Surgical Society
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
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Curet MJ. Resident Work Hour Restrictions: Where Are We Now? J Am Coll Surg 2008; 207:767-76. [DOI: 10.1016/j.jamcollsurg.2008.07.010] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2008] [Revised: 07/15/2008] [Accepted: 07/17/2008] [Indexed: 10/21/2022]
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Dimitris KD, Taylor BC, Fankhauser RA. Resident work-week regulations: historical review and modern perspectives. JOURNAL OF SURGICAL EDUCATION 2008; 65:290-6. [PMID: 18707663 DOI: 10.1016/j.jsurg.2008.05.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2008] [Revised: 05/21/2008] [Accepted: 05/26/2008] [Indexed: 05/20/2023]
Affiliation(s)
- Kirk D Dimitris
- Department of Orthopedic Surgery Mount Carmel Health System, Columbus, Ohio 43222, USA
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Abstract
BACKGROUND The Accreditation Council for Graduate Medical Education resident work hour limitations were implemented in July, 2003. Effects on faculty are not well understood. OBJECTIVE The objective of this study was to determine the effects of the resident work hour limitations on the professional lives of faculty physicians. DESIGN AND PARTICIPANTS Survey of faculty physicians at three teaching hospitals associated with university-based internal medicine and surgery residency programs in Seattle, Washington. Physicians who attended on Internal Medicine and Surgery in-patient services during the 10 mo after implementation of work hour limitations were eligible for participation (N = 366); 282 physicians (77%) returned surveys. MEASUREMENTS Participants were asked about the effects of resident work hour limitations on aspects of their professional lives, including clinical work, research, teaching, and professional satisfaction. RESULTS Most attending physicians reported that, because of work hour limitations, they spent more time on clinical work (52%), felt more responsibility for supervising patient care (65%), and spent less time on research or other academic pursuits (51%) and teaching residents (72%). Reported changes in work content were independently associated with the self-reported probability of leaving academic medicine in the next 3 y. CONCLUSIONS Resident work hour limitations have had large effects on the professional lives of faculty. These findings may have important implications for recruiting and retaining faculty at academic medical centers.
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Kairys JC, McGuire K, Crawford AG, Yeo CJ. Cumulative Operative Experience Is Decreasing During General Surgery Residency: A Worrisome Trend for Surgical Trainees? J Am Coll Surg 2008; 206:804-11; discussion 811-3. [DOI: 10.1016/j.jamcollsurg.2007.12.055] [Citation(s) in RCA: 182] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2007] [Accepted: 12/28/2007] [Indexed: 10/22/2022]
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Dorman T, Pauldine R. Economic stress and misaligned incentives in critical care medicine in the United States. Crit Care Med 2007; 35:S36-43. [PMID: 17242605 DOI: 10.1097/01.ccm.0000252911.62777.1e] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This review will provide an overview of issues with economic ramifications intrinsic to the management of intensive care resources and identify some of the external pressures that ultimately influence the provision of intensive care services. DESIGN A review of the current literature was performed. RESULTS Economic stress is a reality of the management of intensive care resources. The nature of critical care medicine as a technologically heavy, labor intensive, high-cost, limited resource, combined with a projected increase in demand in an era of cost containment, presents an array of challenges. CONCLUSIONS It is in the best interest of the care of our patients that critical care providers increase awareness of the many factors influencing our practice economically. It is through such understanding that challenges can be met, solutions can be found, and the quality of intensive care can be improved in a financially sustainable environment.
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Carlin AM, Gasevic E, Shepard AD. Effect of the 80-hour work week on resident operative experience in general surgery. Am J Surg 2007; 193:326-9; discussion 329-30. [PMID: 17320528 DOI: 10.1016/j.amjsurg.2006.09.014] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2006] [Revised: 09/20/2006] [Accepted: 09/20/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND The goal of this study was to determine the effect of the 80-hour work week on resident operative experience. METHODS General surgery resident operative experience was evaluated during a 4-year period and divided into 2 groups: before (group A [July 1, 2001, to June 30, 2003]) and after (group B July 1, 2003, to June 30, 2005]) implementation of the Accreditation Council for Graduate Medical Education duty hour guidelines. RESULTS There was a significant decrease in mean total and primary surgeon cases in group B for postgraduate year (PGY) levels 1, 2, and 4 (P < or = .001). There was a significant decrease in PGY 5 teaching assistant and PGY 1 first assistant experience in group B (P < or = .001). There was no difference in PGY 3 resident operative volume. CONCLUSIONS The mandated work-hour guidelines have negatively impacted the operative experience of general surgery residents, especially at the junior level. Despite implementing modifications designed to optimize resident operative experience, surgical training programs may require further adaptations.
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Affiliation(s)
- Arthur M Carlin
- Department of Surgery, Henry Ford Hospital, 2799 West Grand Blvd., Detroit, MI 48202, United States.
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Schenarts PJ, Anderson Schenarts KD, Rotondo MF. Myths and Realities of the 80-Hour Work Week. ACTA ACUST UNITED AC 2006; 63:269-74. [PMID: 16843779 DOI: 10.1016/j.cursur.2006.04.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2006] [Revised: 04/07/2006] [Accepted: 04/07/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND Myths are so ingrained into cultural traditions that emotion frequently overshadows a rational evaluation of the facts. The reduction in resident work hours has resulted in the formation of several myths. The purpose of this review is to examine the published data on resident work hours to separate out myth from reality. METHODS An electronic database was searched for publications related to resident training, work-hours, continuity of care, sleep deprivation, quality of life, patient safety, clinical/operative experience, faculty work hours, and surgical education. RESULTS Sleep deprivation has been shown to be harmful, and residents played a role in advocating for work-hour limits. Surgical residents have seen a less dramatic improvement in quality of life compared with other disciplines. Work-hour reductions have decreased participation in clinic but have not resulted in a significant decline in clinical or operative exposure. Limiting resident work hours will unlikely result in a decrease health-care cost. Reduction in resident work hours has not resulted in an improvement or deterioration in patient outcome. Reduction of work hours has not increased faculty work hours nor made surgery a more attractive career choice. CONCLUSIONS Despite strongly held opinions, resident work-hour reduction has resulted in little significant change in lifestyle, clinical exposure, patient well-being, faculty work hours, or medical student recruitment.
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Affiliation(s)
- Paul J Schenarts
- Department of Surgery, East Carolina University, Brody School of Medicine, Greenville, NC 27858, USA.
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Nwomeh BC, Georges AJ, Groner JI, Haley KJ, Hayes JR, Caniano DA. A leap in faith: the impact of removing the surgeon from the level II trauma response. J Pediatr Surg 2006; 41:693-9; discussion 693-9. [PMID: 16567178 DOI: 10.1016/j.jpedsurg.2005.12.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Limitation of resident work hours has created the need to explore alternatives to surgeon presence during initial assessment and resuscitation for selected life-threatening injuries in children. We recently eliminated the requirement for surgeon presence during Level II alerts. The purpose of this study was to evaluate the impact of this change on patient care. METHODS A retrospective analysis of trauma alert activity was performed using data from our trauma registry. In March 2003, responsibility for level II alerts was transferred from the pediatric surgeons (PSs) to the Emergency Department (ED) physicians. We compared the activity in the 18-month period before this change (period 1; n = 627) to that afterward (period 2; n = 587). Outcome measures included injury severity score, emergency department length of stay, missed injuries, abdominal computed tomography use, and mortality. Data were analyzed using log-rank statistic, chi2, or t test, where appropriate, with significance level at P < .05. RESULTS During the entire study period, 1499 patients met the trauma alert activation criteria of which 1214 (81%) were level II alerts. The mean injury severity score for period 1 (8.5 +/- 7.3 SD) was similar to period 2 (9.0 +/- 7.1 SD). When ED physicians replaced PS for Level II alerts, ED length of stay increased from 135 minutes to 165 minutes (P < .001). In addition, the use of abdominal computed tomography was significantly decreased (53.6% vs 42.6%; P < .001). However, there were no missed injuries and no significant differences in the rate of mortality. CONCLUSIONS When ED physicians replaced PS for Level II alerts, trauma room length of stay was increased, but use of abdominal imaging was decreased with no differences in rate of missed injury or mortality. Emergency Department physicians can safely replace PS during Level II alerts. These findings may be useful to institutions experiencing surgical workforce limitations for trauma alerts.
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Affiliation(s)
- Benedict C Nwomeh
- Division of Pediatric Surgery, Department of Surgery, The Ohio State University College of Medicine and Public Health, Children's Hospital, Columbus, OH 43205, USA.
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Abstract
PURPOSE OF REVIEW This review addresses the way in which sleep physiology influences the medical profession and health care delivery. RECENT FINDINGS The training process for the medical professional has undergone dramatic changes over the past century. In recent times, however, the complexity and level of care delivered has out-stripped a trainee's ability to forego sleep and is compromising both physician and patient safety and thereby threatens the foundation of the profession. Recently, significant strides have been made in our understanding of sleep loss and consequences to physicians-in-training. Nevertheless, the implementation of changes fostered by such findings faces numerous conceptual and practical obstacles. This review updates the reader on recent evidence for changing the way medical professionals are trained, and opines on how solutions generated from such research should be embraced. Additionally, the deficiencies in our current understanding of sleep and medical training are identified so that future research can be undertaken in such areas. SUMMARY Acknowledging the defects in our current system of training physicians and enacting further changes is sorely needed to improve patient safety and the well-being of physicians-in-training.
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Affiliation(s)
- Sairam Parthasarathy
- Section of Pulmonary and Critical Care Medicine, Southern Arizona Veterans Administrative Health Care System, University of Arizona, Tucson, Arizona 85723, USA.
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Kennedy TJT, Regehr G, Baker GR, Lingard LA. Progressive independence in clinical training: a tradition worth defending? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2005; 80:S106-11. [PMID: 16199447 DOI: 10.1097/00001888-200510001-00028] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
BACKGROUND Progressive independence is a traditional premise of clinical training. Recently, issues such as managed care, work hours limitation, and patient safety have begun to impact the degree of autonomy afforded to clinical trainees. This article reviews empirical evidence and theory pertaining to the role of progressive autonomy in clinical learning. METHOD A computerized literature search was performed using Medline, PsycINFO, Social Sciences Citation Index, and Educational Resources Information Center. This article presents a synthetic review of relevant empirical and theoretical concepts from the domains of medicine, psychology, education, kinesiology, and sociology. RESULTS The clinical psychology and medical education literatures provide evidence that clinical trainees act more independently as their training progresses, but have not yet evaluated the educational efficacy of providing progressive independence, or the consequences of failing to do so. The expertise and motor learning literatures provide some theoretical evidence (as yet untested in complex clinical environments) that the provision of too much guidance or feedback to trainees could be educationally detrimental in the long term. The sociology literature provides insight into the cultural values underlying the behavior of clinical teachers and trainees relating to issues of supervision and independence. CONCLUSIONS There is limited empirical support for the current model of progressive independence in clinical learning; however, diverse theoretical perspectives raise concern about the potential educational consequences of eroding progressive independence. These perspectives could inform future research programs that would create a creative and effective response to the social and economic forces impacting clinical education.
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Affiliation(s)
- Tara J T Kennedy
- Wilson Centre for Research in Education at the University Health Network, 200 Elizabeth Street, Eaton South 1-565, Toronto, Ontario, Canada M5G 2C4.
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