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

Advancing spinal fellowship training: an international multi-centre educational perspective

PURPOSE

The purpose of this article is to review the importance of contemporary spine surgery fellowships and educational strategies to assist with fellowship design and delivery.

METHODS

Spine surgery fellowship includes trainees from orthopaedic and neurosurgical backgrounds and is increasingly indicated for individuals wishing to pursue spine surgery as a career, recognizing how spinal surgery evolved significantly in scope and complexity. We combine expert opinion with a review of the literature and international experience to expound spine fellowship training.

RESULTS

Contemporary learning techniques include boot camps at the start of fellowship which may reinforce previous clinical learning and help prepare fellows for their new clinical roles. There is good evidence that surgical specialty training boot camps improve clinical skills, knowledge and trainee confidence prior to embarking upon new clinical roles with increasing levels of responsibility. Furthermore, as simulation techniques and technologies take on an increasing role in medical and surgical training, we found evidence that trainees' operative skills and knowledge can improve with simulated operations, even if just carried out briefly. Finally, we found evidence to suggest a role for establishing competence-based objectives for training in specific operative and technical procedures. Competence-based objectives are helpful for trainees and trainers to highlight gaps in a trainee's skill set that may then be addressed during training.

CONCLUSIONS

Spinal fellowships may benefit from certain contemporary strategies that assist design and delivery of training in a safe environment. Interpersonal factors that promote healthy teamwork may contribute to an environment conducive to learning. These slides can be retrieved under Electronic Supplementary Material.

Canadian Plastic Surgery Resident Work Hour Restrictions: Practices and Perceptions of Residents and Program Directors

Background

The impact of resident work hour restrictions on training and patient care remains a highly controversial topic, and to date, there lacks a formal assessment as it pertains to Canadian plastic surgery residents.

Objective

To characterize the work hour profile of Canadian plastic surgery residents and assess the perspectives of residents and program directors regarding work hour restrictions related to surgical competency, resident wellness, and patient safety.

Methods

An anonymous online survey developed by the authors was sent to all Canadian plastic surgery residents and program directors. Basic summary statistics were calculated.

Results

Eighty (53%) residents and 10 (77%) program directors responded. Residents reported working an average of 73 hours in hospital per week with 8 call shifts per month and sleep 4.7 hours/night while on call. Most residents (88%) reported averaging 0 post-call days off per month and 61% will work post-call without any sleep. The majority want the option of working post-call (63%) and oppose an 80-hour weekly maximum (77%). Surgical and medical errors attributed to post-call fatigue were self-reported by 26% and 49% of residents, respectively. Residents and program directors expressed concern about the ability to master surgical skills without working post-call.

Conclusions

The majority of respondents oppose duty hour restrictions. The reason is likely multifactorial, including the desire of residents to meet perceived expectations and to master their surgical skills while supervised. If duty hour restrictions are aggressively implemented, many respondents feel that an increased duration of training may be necessary.

Resident Physician Duty-hour Requirements: What Does the Public Think?

INTRODUCTION

To date, no study has reported on the public's opinion of orthopaedic resident duty-hour requirements (DHR).

METHODS

A survey was administered to people in orthopaedic waiting rooms and at three senior centers. Responses were analyzed to evaluate seven domains: knowledge of duty hours; opinions about duty hours; attitudes regarding shift work; patient safety concerns; and the effects of DHRs on continuity of care, on resident training, and on resident professionalism.

RESULTS

Respondents felt that fatigue was unsafe and duty hours were beneficial in preventing resident physician fatigue. They supported the idea of residents working in shifts but did not support shifts for attending physicians. However, respondents wanted the same resident to provide continuity of care, even if that violated DHRs. They were supportive of increasing the length of residency to complete training. DHRs were not believed to affect professionalism. Half of the respondents believed that patient opinion should influence policy on this topic.

DISCUSSION

Orthopaedic patients and those likely to require orthopaedic care have inconsistent opinions regarding DHRs, making it potentially difficult to incorporate their preferences into policy.

Orthopedic Residency: Are Duty Hours Predictive of Performance?

OBJECTIVE

This study examines the relationship between self-recorded resident work hours and Orthopedic In-training Examination (OITE) scores, resident clinical performance, and American Board of Orthopedic Surgery pass rates. The hypothesis of this study is that increasing duty hours would have a positive correlation with clinical and OITE performance.

DESIGN

Total duty hours and recorded operating room hours from a single orthopedic residency program were extracted from 2006 to 2012. During the same time span, OITE scores, resident clinical scores from the E-Valuation system, and American Board of Orthopedic Surgery pass rates were collected. The correlation between the variables was assessed using the Pearson correlation coefficient's precision statistic.

SETTING

A large public tertiary academic center in the upper Midwestern United States.

PARTICIPANTS

A total of 82 orthopedic surgery residents over 7 years.

RESULTS

A total of 82 residents were matriculated between 2006 and 2012. The average weekly recorded duty hours were as follows: postgraduate year 2 (PGY2) = 60 hours/week (Standard Deviation (SD) ± 4), PGY3 = 59 hours/week (SD ± 5), PGY4 = 51 hours/week (SD ± 4), PGY5 = 49 hours/week (SD ± 3). There was significant variability in the average number of hours worked among residents (range: 2128-3753h/y) for the full academic year. The OITE scores and the work hours were found to be independent of each other (ρ = 0.017, p = 0.825), and no correlation was found between OITE scores and the resident E-value scores (ρ = 0.071, p = 0.34). Residents spent 36% to 48% of their time in the operating room. Second year residents logging more hours scored higher on faculty evaluation of overall competency (ρ = 0.31, p = 0.035). Faculty assessment of technical skills had a positive correlation with operating room duty hours for PGY5 class (ρ = 0.346, p = 0.025).

CONCLUSIONS

A large variation in duty hours exists between resident-logged duty hours. No correlation exists between in-training scores and duty hours. There is a positive correlation between senior resident operating room hours and technical skill scores.

Work-hour restrictions and orthopaedic resident education: a systematic review

PURPOSE

The ACGME (US) and The European Working Time Directive (UK) placed work-hour restrictions on medical trainees with the goal of improved patient safety. However, there has been concern over a potential decrease in medical education. Orthopaedic training is the focus of this study. We examined previously published subjective and objective data regarding education and work-hour restrictions and developed the questions: Do specific perceptions emerge within the subjective studies examined? Are there objective differences in educational measures before and after work-hour restrictions? Is there a difference between the subjective and objective data?

METHODS

A systematic review was conducted via MedLine, regarding orthopaedic studies in the USA and UK, with reference to work-hour restrictions and education.

RESULTS

Subjective survey studies demonstrate that residents and attending physicians have a negative response to work-hour restrictions because of the perceived impact on their overall education and operating room experience. Conversely, limited objective studies demonstrated no change in operative volume before or after implementation of restrictions.

CONCLUSIONS

This review highlights the need for more objective studies on the educational implications of work-hour restrictions. Studies to date have not demonstrated a measurable difference based on case logs or training scores. Opinion-based surveys demonstrate an overall negative perception by both residents and attending physicians, on the impact of work-hour restrictions on orthopaedic education. Current published data is limited and stronger evidence-based data are needed before definitive conclusions can be reached.

What effects have resident work-hour changes had on education, quality of life, and safety? A systematic review

BACKGROUND

More than 15 years ago, the Institute of Medicine (IOM) identified medical error as a problem worthy of greater attention; in the wake of the IOM report, numerous changes were made to regulations to limit residents' duty hours. However, the effect of resident work-hour changes remains controversial within the field of orthopaedics.

QUESTIONS/PURPOSES

We performed a systematic review to determine whether work-hour restrictions have measurably influenced quality-of-life measures, operative and technical skill development, resident surgical education, patient care outcomes (including mortality, morbidity, adverse events, sentinel events, complications), and surgeon and resident attitudes (such as perceived effect on learning and training experiences, personal benefit, direct clinical experience, clinical preparedness).

METHODS

We performed a systematic review of PubMed, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Google Scholar using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were any English language peer-reviewed articles that analyzed the effect(s) of orthopaedic surgery resident work-hour restrictions on patient safety, resident education, resident/surgeon quality of life, resident technical operative skill development, and resident surgeon attitudes toward work-hour restrictions. Eleven studies met study inclusion criteria. One study was a prospective analysis, whereas 10 studies were of level IV evidence (review of surgical case logs) or survey results.

RESULTS

Within our identified studies, there was some support for improved resident quality of life, improved resident sleep and less fatigue, a perceived negative impact on surgical operative and technical skill, and conflicting evidence on the topic of resident education, patient outcomes, and variable attitudes toward the work-hour changes.

CONCLUSIONS

There is a paucity of high-level or clear evidence evaluating the effect of the changes to resident work hours. Future research in this area should focus on objective measures that include patient safety as a primary outcome.

Orthopaedic residency applications increase after implementation of 80-hour workweek

BACKGROUND

The factors that influence interest among medical students toward different medical specialties with time are important. The potential impact of changes in work-hour rules on orthopaedic applications in comparison to that of primary care medicine has not been reported. The change in number of applicants to general surgery during this period also is unknown.

QUESTIONS/PURPOSES

The goals of our study were to assess the changes in orthopaedic applications relative to the 80-hour workweek and to compare these changes with those in the primary care field. We also documented the change in applications to general surgery after the work-hour changes.

METHODS

A retrospective analysis of data from the National Resident Matching Program, San Francisco Matching Programs, and the American Urological Association from 1997 to 2010 was performed. Two cohorts of medical school applicants to primary care and surgery were established: those who applied from 1997 to 2002, predating work-hour changes, and those who applied from 2005 to 2010, after implementation of the 80-hour regulation. From the surgical data, applications to orthopaedic and general surgery were subselected and analyzed. Data were analyzed from a total applicant pool of 111,973 representing primary care and surgery applications. There were 59,996 and 51,977 applicants before and after the work-hour changes, respectively.

RESULTS

Applications to orthopaedics increased by 21% (3310 to 4011 applicants) after implementation of work-hour changes, whereas primary care applications decreased by 18% (42,587 to 34,884 applicants) after the work-hour rules. General surgery applications decreased by 24% during this period.

CONCLUSIONS

Residency applications to orthopaedic surgery have increased since inception of the 80-hour workweek. By contrast, applications to primary care programs and general surgery have decreased after implementation of work-hour restrictions.

A narrative review of surgical resident duty hour limits: where do we go from here?

BACKGROUND

Resident duty hour limits have been a point of debate among educators, administrators, and policymakers alike since the Libby Zion case in 1984. Advocates for duty hour limits in the surgical subspecialties cite improvements in patient safety, whereas opponents claim that limiting resident duty hours jeopardizes resident education and preparedness for independent surgical practice.

METHODS

Using orthopaedic surgery as an example, we describe the historical context of the implementation of the duty hour standards, provide a review of the literature presenting data that both supports and refutes continued restrictions, and outline suggestions for policy going forward that prioritize patient safety while maintaining an enhanced environment for resident education.

RESULTS

Although patient safety markers have improved in some studies since the implementation of duty hour limits, it is unclear whether this is due to changes in residency training or external factors. The literature is mixed regarding academic performance and trainee readiness during and after residency.

CONCLUSION

Although excessive duty hours and resident fatigue may have historically contributed to errors in the delivery of patient care, those are certainly not the only concerns. An overall "culture of safety," which includes pinpointing systematic improvements, identifying potential sources of error, raising performance standards and safety expectations, and implementing multiple layers of protection against medical errors, can continue to augment safety barriers and improve patient care. This can be achieved within a more flexible educational environment that protects resident education and ensures optimal training for the next generation of physicians and surgeons.

Perspective: Integrating research into surgical residency education: lessons learned from orthopaedic surgery

Orthopaedic research has advanced tremendously in parallel with accelerated progress in medical science. Possession of a fundamental understanding of basic and clinical science has become more essential than previously for orthopaedic surgeons to be able to translate advances in research into clinical practice. The number of medical graduates with prior education in scientific research who choose to pursue careers in orthopaedic surgery is small. Therefore, it is important that a core of research education be included during residency training to ensure the continued advancement of the clinical practice of orthopaedics. The authors examine some of the challenges to a comprehensive research experience during residency, including deficient priority, inadequate institutional infrastructure, financial strain on residency budgets, restricted time, and an insufficient number of mentors to encourage and guide residents to become clinician-scientists. They also present some strategies to overcome these challenges, including development and expansion of residency programs with clinician-scientist pathways, promotion of financial sources, and enhancement of opportunities for residents to interact with mentors who can serve as role models. Successful integration of research education into residency programs will stimulate future orthopaedic surgeons to develop the critical skills to lead musculoskeletal research, comprehend related discoveries, and translate them into patient care. Lessons learned from incorporating research training within orthopaedic residency programs will have broad application across medical specialties-in both primary and subspecialty patient care.

Cost implications of ACGME's 2011 changes to resident duty hours and the training environment

BACKGROUND

In July 2011, the Accreditation Council for Graduate Medical Education (ACGME) will implemented stricter duty-hour limits and related changes to the training environment. This may affect preventable adverse event (PAE) rates.

OBJECTIVES

To estimate direct costs under various implementation approaches, and examine net costs to teaching hospitals and cost-effectiveness to society across a range of hypothetical changes in PAEs.

DESIGN

A decision-analytical model represented direct costs and PAE rates, mortality, and costs.

DATA SOURCES

Published literature and publicly available data.

TARGET POPULATION

Patients admitted to hospitals with ACGME-accredited programs.

TIME HORIZON

One year.

PERSPECTIVES

All teaching hospitals, major teaching hospitals, society.

INTERVENTION

ACGME's 2011 Common Program Requirements.

OUTCOME MEASURES

Direct annual costs (all accredited hospitals), net cost (major teaching hospitals), cost per death averted (society). RESULTS OF BASE-ANALYSIS: Nationwide, duty-hour changes would cost $177 million annually if interns maintain current productivity, vs. up to $982 million if they transfer work to a mixture of substitutes; training-environment changes will cost $204 million. If PAEs decline by 7.2-25.8%, net costs to major teaching hospitals will be zero. If PAEs fall by 3%, the cost to society per death averted would be -$523,000 (95%-confidence interval: -$1.82 million to $685,000) to $2.44 million ($271,000 to $6.91 million). If PAEs rise, the policy will be cost-increasing for teaching hospitals and society.

RESULTS OF SENSITIVITY ANALYSIS

The total direct annual cost nationwide would be up to $1.34 billion using nurse practitioners/physician assistants, $1.64 billion using attending physicians, $820 million hiring additional residents, vs. 1.42 billion using mixed substitutes.

LIMITATIONS

The effect on PAEs is unknown. Data were limited for some model parameters.

CONCLUSION

Implementation decisions greatly affect the cost. Unless PAEs decline substantially, teaching hospitals will lose money. If PAEs decline modestly, the requirements might be cost-saving or cost-effective to society.

What opportunities are available for resident involvement in national orthopedic and subspecialty societies?

As physician involvement in health policy grows, there will be an increasing need for future leaders in orthopedics. Interested orthopedic residents may be unaware of opportunities for leadership involvement in professional and subspecialty organizations. This article investigates whether national and subspecialty organizations offer membership to residents, allow residents to participate in committees, and provide opportunities for scholarly activity and mentorship. The authors surveyed 20 national orthopedic professional and subspecialty societies to evaluate the availability and cost of resident membership, meeting attendance and participation, research funding, committee membership, and mentorship opportunities. Each society's Web site was reviewed, and societies were contacted by phone if further inquiry was needed. Of the 20 orthopedic societies surveyed, 11 allowed resident membership. Five of 20 societies allowed residents to serve on committees, with a total of 14 total positions for residents. Four organizations provided formalized mentorship programs to residents. Although opportunities for resident involvement in subspecialty and professional societies are available in the majority of groups surveyed, the Orthopaedic Trauma Association and American Society for Surgery of the Hand provided the most comprehensive collection of opportunities. Residents should also pursue involvement in other organizations that may be more readily accessible, such as local, state, and regional orthopedic and medical societies. Increased resident participation in these organizations may help in increasing the 14 nationally available committee positions for orthopedic residents. Our orthopedic profession and societies should encourage motivated residents to pursue involvement and leadership at the national level.

Changes in the number of resident publications after inception of the 80-hour work week

BACKGROUND

Since the inception of resident work-hour regulations, there has been considerable concern regarding the influence of decreased work hours on graduate medical education. In particular, it is unclear whether implementation of work-hour restrictions has influenced resident academic performance as defined by quantity of peer-reviewed publications while participating in graduate medical education.

QUESTIONS/PURPOSES

We determined the impact of work-hour changes on resident involvement in the number of published clinical studies, laboratory research, case reports, and review articles.

METHODS

We conducted a PubMed literature search of 139 consecutive orthopaedic surgery residents (789 total resident-years) at one institution from academic years 1995-1996 to 2008-2009. This represented a continuous timeline before and after implementation of work-hour restrictions. The number of resident publications before and after implementation of work-hour changes was compared.

RESULTS

There was a greater probability of peer review authorship in any given resident-year after work-hour changes than before. Average publications per resident-year increased for total articles, clinical articles, case reports, and reviews. There was an increased rate of publications in which the resident was the first author.

CONCLUSIONS

Since implementation of work-hour changes, total resident publications and publications per resident-year have increased.

Challenges for Large Orthopaedic Hospitals Worldwide-An ISOC Position Statement

Since the foundation of the International Society of Orthopaedic Centers in 2006, the group has continued to grow, with currently 11 members worldwide. During the 2008 annual meeting, the bylaws and mission of the group were approved as well as the acceptance of two additional members. Strict inclusion criteria were established to keep the group both small and effective. The goal of the 2008 meeting and this position statement is to identify current challenges in both research and education for large-volume orthopedic hospitals and to discuss possible approaches and solutions.

Cost implications of reduced work hours and workloads for resident physicians

BACKGROUND

Although the Accreditation Council for Graduate Medical Education (ACGME) limits the work hours of residents, concerns about fatigue persist. A new Institute of Medicine (IOM) report recommends, among other changes, improved adherence to the 2003 ACGME limits, naps during extended shifts, a 16-hour limit for shifts without naps, and reduced workloads.

METHODS

We used published data to estimate labor costs associated with transferring excess work from residents to substitute providers, and we examined the effects of our assumptions in sensitivity analyses. Next, using a probability model to represent labor costs as well as mortality and costs associated with preventable adverse events, we determined the net costs to major teaching hospitals and cost-effectiveness across a range of hypothetical changes in the rate of preventable adverse events.

RESULTS

Annual labor costs from implementing the IOM recommendations were estimated to be $1.6 billion (in 2006 U.S. dollars) across all ACGME-accredited programs ($1.1 billion to $2.5 billion in sensitivity analyses). From a 10% decrease to a 10% increase in preventable adverse events, net costs per admission ranged from $99 to $183 for major teaching hospitals and from $17 to $266 for society. With 2.5% to 11.3% decreases in preventable adverse events, costs to society per averted death ranged from $3.4 million to $0.

CONCLUSIONS

Implementing the four IOM recommendations would be costly, and their effectiveness is unknown. If highly effective, they could prevent patient harm at reduced or no cost from the societal perspective. However, net costs to teaching hospitals would remain high.

A brief comparison of orthopaedic training in English-speaking countries

The purpose of this article is to examine current orthopaedic training in the UK and objectively compare this with other English-speaking countries.

Expansion of the coordinator role in orthopaedic residency program management

The Accreditation Council of Graduate Medical Education's (ACGME) Data Accreditation System indicates 124 of 152 orthopaedic surgery residency program directors have 5 or fewer years of tenure. The qualifications and responsibilities of the position based on the requirements of orthopaedic surgery residency programs, the institutions that support them, and the ACGME Outcome Project have evolved the role of the program coordinator from clerical to managerial. To fill the void of information on the coordinators' expanding roles and responsibilities, the 2006 Association of Residency Coordinators in Orthopaedic Surgery (ARCOS) Career survey was designed and distributed to 152 program coordinators in the United States. We had a 39.5% response rate for the survey, which indicated a high level of day-to-day managerial oversight of all aspects of the residency program; additional responsibilities for other department or division functions for fellows, rotating medical students, continuing medical education of the faculty; and miscellaneous business functions. Although there has been expansion of the role of the program coordinator, challenges exist in job congruence and position reclassification. We believe use of professional groups such as ARCOS and certification of program coordinators should be supported and encouraged.