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A Dual-Institutional Study on First Year Practice Outcomes of Pediatric Surgeons Who Trained in the Era of Work Hour Restrictions. Pediatr Surg Int 2022; 38:277-283. [PMID: 34709434 PMCID: PMC8742777 DOI: 10.1007/s00383-021-05037-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND In July 2003, an 80-h work week restriction for residencies was mandated. This was met with skepticism regarding its potential impact on operative training. We hypothesized no difference in outcomes for pediatric surgeons who trained under duty hour restrictions compared to historical complication rates. METHODS Dual-institutional review of pediatric patients who underwent five of the most common operations (2013-2018) by first-year pediatric surgeons who trained under duty hour restrictions was performed. Tests of proportions were used to compare complication rates to published rates on data collected prior to 2003. RESULTS Patient mean age was 10.1 years. No significant differences (p values > 0.05) were found in laparoscopic appendectomy rates of infection, bleeding or intra-abdominal abscess compared to previously published rates. Pyloromyotomy rates of infection or duodenal perforation were not different. No differences were detected in rates of infection, recurrence or testicular atrophy for inguinal hernia repair. Umbilical hernia rates of infection, bleeding, and recurrence were also not different. There was no difference in CVC rates of hemopneumothoraces; significantly more bleeding events were detected (1.2% vs. 0.1%; p value = 0.04). CONCLUSION In this study, first-year complication rates of pediatric surgeons who trained under duty hour restrictions were not significantly different when compared to published rates.
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Larson DP, Carlson ML, Lohse CM, O'Brien EK, Kircher ML, Gurgel RK, Hunter JB, Micco AG, Nogan SJ, O'Connell BP, Rangarajan SV, Rivas A, Sweeney AD, Wanna GB, Weisskopf PA, Choby G. Prevalence of and Associations With Distress and Professional Burnout Among Otolaryngologists: Part I, Trainees. Otolaryngol Head Neck Surg 2020; 164:1019-1029. [PMID: 32988285 DOI: 10.1177/0194599820959273] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To assess the prevalence of distress and burnout in otolaryngology trainees, including associations with relevant sociodemographic and professional factors, and to compare these results with those of attending otolaryngologists. STUDY DESIGN A cross-sectional survey of trainees and attending physicians. SETTING Twelve academic otolaryngology programs. METHODS Distress and burnout were measured with the Expanded Physician Well-being Index and the 2-item Maslach Burnout Inventory. The Patient Health Questionnaire-2 and Generalized Anxiety Disorder-2 were used to screen for depressive disorders and anxiety disorders, respectively. Associations with sociodemographic and professional characteristics were assessed. RESULTS Of the 613 surveys administered to trainees and attending physicians, 340 were completed (56%). Among 154 trainees, distress was present in 49%, professional burnout in 35%, positive depressive disorder screening in 5%, and positive anxiety disorder screening in 16%. In univariable analysis, female gender, hours worked in a typical week (HW), and nights on call in a typical week (NOC) were significantly associated with distress. In multivariable analysis, female gender (odds ratio, 3.91; P = .001) and HW (odds ratio for each 10 HW, 1.89; P = .003) remained significantly associated with distress. Female gender, HW, and NOC were significantly associated with burnout univariably, although only HW (odds ratio for each 10 HW, 1.92; P = .003) remained significantly associated with burnout in a multivariable setting. Attending physicians had less distress than trainees (P = .02) and felt less callous and less emotionally hardened than trainees (P < .001). CONCLUSION Otolaryngology trainees experience significant work-place distress (49%) and burnout (35%). Gender, HW, and NOC had the strongest associations with distress and burnout.
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Affiliation(s)
- David P Larson
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew L Carlson
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Christine M Lohse
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Erin K O'Brien
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew L Kircher
- Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Richard K Gurgel
- Division of Otolaryngology-Head and Neck Surgery, University of Utah Medical Center, Salt Lake City, Utah, USA
| | - Jacob B Hunter
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Alan G Micco
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University, Chicago, Illinois, USA
| | - Stephen J Nogan
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Brendan P O'Connell
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sanjeet V Rangarajan
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee, Memphis, Tennessee, USA
| | - Alejandro Rivas
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alex D Sweeney
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - George B Wanna
- Department of Otolaryngology-Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA
| | - Peter A Weisskopf
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Scottsdale, Arizona, USA
| | - Garret Choby
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
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West JL, Fargen KM, Aschenbrenner CA, Wilson JA, Branch CL, Wolfe SQ, Hsu W. Commentary: Resident Operative Experience: Training an Expert Neurosurgeon. Neurosurgery 2019; 84:E279-E286. [DOI: 10.1093/neuros/nyz015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- James L West
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Carol A Aschenbrenner
- Division of Public Health Sciences, Department of Biostatistics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - John A Wilson
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Charles L Branch
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Wesley Hsu
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Zavlin D, Chegireddy V, Nguyen-Lee JJ, Shih L, Nia AM, Friedman JD, Echo A. Training Effects of Visual Stroboscopic Impairment on Surgical Performance: A Randomized-Controlled Trial. JOURNAL OF SURGICAL EDUCATION 2019; 76:560-567. [PMID: 30131280 DOI: 10.1016/j.jsurg.2018.07.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/08/2018] [Accepted: 07/22/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE There have been numerous advances to accelerate and improve quality and dexterous proficiency of surgical training to meet the growing US demand of graduating surgeons. The authors aimed to investigate the learning effects of such limited visual input on the surgical proficiency in untrained novice surgeons. DESIGN A prospective randomized-controlled study was created with 11 participants in the study and 11 in the control group. SETTING An inanimate surgical simulation lab of a tertiary academic institution (Houston Methodist Hospital, Houston, Texas). PARTICIPANTS Adult medical students in the experimental group were wearing stroboscopic eyewear while performing the same tasks as students in the control group with normal vision. For 5 weeks, the subjects were scored during 3 standardized surgical tasks from the American College of Surgeons and the Association of Program Directors in Surgery Resident Skills Curriculum: knot tying, simple interrupted sutures, and a running stitch. Pretrial, we employed the State-Trait Anxiety Inventory and post-trial, the NASA Task Load Index. RESULTS The demographic characteristics of our study participants were uniformly distributed between the 2 cohorts: each group had 7 males and 4 females. Average ages were 23.6 and 24.2 years (p = 0.471). The anxiety was low during all 5 sessions and indifferent between both groups. At the end of the study, no changes were observed in the stroboscopic group for the knot-tying task (p = 0.619). However, for the simple interrupted and the running stitch, the students with stroboscopic glasses performed significantly better (p = 0.001 and p = 0.024, respectively). The stroboscopic students also had significantly lower NASA workload scores (p = 0.001). CONCLUSIONS Regular training with stroboscopic glasses that limit visual input has a significant positive effect on the technical skills of novice surgical trainees with regards to more complex tasks such as multiple simple interrupted suturing or running suture. Intermittently impaired vision is beneficial in the early education of students and surgical residents.
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Affiliation(s)
- Dmitry Zavlin
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas.
| | - Vishwanath Chegireddy
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas; Department of Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas
| | - John J Nguyen-Lee
- Department of Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas
| | - Linden Shih
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas
| | - Anna M Nia
- School of Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Jeffrey D Friedman
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas
| | - Anthony Echo
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas.
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Alexander D, Thrasher M, Hughley B, Woodworth BA, Carroll W, Willig JH, Cho DY. Gamification as a tool for resident education in otolaryngology: A pilot study. Laryngoscope 2018; 129:358-361. [PMID: 30421431 DOI: 10.1002/lary.27286] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2018] [Indexed: 11/09/2022]
Affiliation(s)
- David Alexander
- Department of Otolaryngology-Head and Neck Surgery, Birmingham, Alabama, U.S.A
| | - Michelle Thrasher
- Department of Otolaryngology-Head and Neck Surgery, Birmingham, Alabama, U.S.A
| | - Brian Hughley
- Department of Otolaryngology-Head and Neck Surgery, Birmingham, Alabama, U.S.A
| | | | - William Carroll
- Department of Otolaryngology-Head and Neck Surgery, Birmingham, Alabama, U.S.A
| | - James H Willig
- Division of Infectious Disease, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Do-Yeon Cho
- Department of Otolaryngology-Head and Neck Surgery, Birmingham, Alabama, U.S.A
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Naik ND, Abbott EF, Aho JM, Pandian TK, Thiels CA, Heller SF, Farley DR. The ACGME Case Log System May Not Accurately Represent Operative Experience Among General Surgery Interns. JOURNAL OF SURGICAL EDUCATION 2017; 74:e106-e110. [PMID: 29055744 DOI: 10.1016/j.jsurg.2017.09.032] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 09/28/2017] [Accepted: 09/30/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To assess if the Accreditation Council for Graduate Medical Education (ACGME) case log system accurately captures operative experience of our postgraduate year 1 (PGY-1) residents. DESIGN ACGME case log information was retrospectively obtained for 5 cohorts of PGY-1 residents (2011-2015) and compared to the number of operative cases captured by an institutional automated operative case report system, Surgical Access Utility System (SAUS). SAUS automatically captures all surgical team members who are listed in the operative dictation for a given case, including interns. A paired t-test analysis was used to compare number of cases coded between the 2 systems. SETTING Academic, tertiary care referral center with a large general surgery training program. PARTICIPANTS PGY-1 general surgery trainees (interns) from the years 2011-2015. RESULTS Forty-nine PGY-1 general surgery residents were identified over a 5-year period. Mean operative case volume per intern, per year, captured by the automated SAUS was 176.5 ± 28.1 (SD) compared to 126.3 ± 58.0 ACGME cases logged (mean difference = 50.2 cases, p < 0.001). CONCLUSIONS ACGME case log data may not accurately reflect the actual operative experience of our PGY-1 residents. If such data holds true for other general surgery training programs, the true impact of duty hour regulations on operative volume may be unclear when using the ACGME case log data. This current standard approach for using ACGME case logs as a representation of operative experience requires further scrutiny and potential revision to more accurately determine operative experience for accreditation purposes.
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Affiliation(s)
- Nimesh D Naik
- Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Eduardo F Abbott
- Multidisciplinary Simulation Center, Mayo Clinic, Rochester, Minnesota; Department of Internal Medicine, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Johnathon M Aho
- Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - T K Pandian
- Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Cornelius A Thiels
- Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Stephanie F Heller
- Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - David R Farley
- Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota; Multidisciplinary Simulation Center, Mayo Clinic, Rochester, Minnesota.
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Ban VS, Madden CJ, Browning T, O'Connell E, Marple BF, Moran B. A novel use of the discrete templated notes within an electronic health record software to monitor resident supervision. J Am Med Inform Assoc 2017; 24:e2-e8. [PMID: 27274023 DOI: 10.1093/jamia/ocw078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 04/19/2016] [Indexed: 12/26/2022] Open
Abstract
Objective Monitoring the supervision of residents can be a challenging task. We describe our experience with the implementation of a templated note system for documenting procedures with the aim of enabling automated, discrete, and standardized capture of documentation of supervision of residents performing floor-based procedures, with minimal extra effort from the residents. Materials and methods Procedural note templates were designed using the standard existing template within a commercial electronic health record software. Templates for common procedures were created such that residents could document every procedure performed outside of the formal procedural areas. Automated reports were generated and letters were sent to noncompliers. Results A total of 27 045 inpatient non-formal procedural area procedures were recorded from August 2012 to June 2014. Compliance with NoteWriter template usage averaged 86% in the first year and increased to 94.6% in the second year ( P = .0055). Initially, only 12.5% of residents documented supervision of any form. By the end of the first year, this was above 80%, with the gains maintained into the second year and beyond. Direct supervision was documented to have occurred where required in 62.8% in the first year and increased to 99.8% in the second year ( P = .0001) after the addition of hard stops. Notification of attendings prior to procedures was documented 100% of the time by September 2013. Letters sent to errant residents decreased from 3.6 to 0.83 per 100 residents per week. Conclusion The templated procedure note system with hard stops and integrated reporting can successfully be used to improve monitoring of resident supervision. This has potential impact on resident education and patient safety.
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Affiliation(s)
- Vin Shen Ban
- Department of Neurological Surgery, University of Texas Southwestern Medical Center
| | - Christopher J Madden
- Department of Neurological Surgery, University of Texas Southwestern Medical Center.,Office of the Executive Vice President, Parkland Health and Hospital System, Dallas, Texas
| | - Travis Browning
- Department of Radiology and Division of Informatics, University of Texas Southwestern Medical Center
| | - Ellen O'Connell
- Department of Emergency Medicine, University of Texas Southwestern Medical Center and Parkland Health and Hospital System
| | - Bradley F Marple
- Department of Otolaryngology and Graduate Medical Education, University of Texas Southwestern Medical Center
| | - Brett Moran
- Department of Internal Medicine, University of Texas Southwestern Medical Center.,Information Technology, Parkland Health and Hospital System, Dallas, Texas
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Paediatric cardiology fellowship training: effect of work-hour regulations on scholarly activity. Cardiol Young 2017; 27:69-73. [PMID: 26956034 DOI: 10.1017/s1047951116000123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND In 2003, work-hour regulations were implemented by the Accreditation Council for Graduate Medical Education. Much has been published regarding resident rest and quality of life as well as patient safety. There has been no examination on the effect of work-hour restrictions on academic productivity of fellows in training. Paediatric subspecialty fellows have a scholarly requirement mandated by the American Board of Pediatrics. We have examined the impact of work-hour restrictions on the scholarly productivity of paediatric cardiology fellows during their fellowship. METHODS We conducted a literature search for all paediatric cardiology fellows between 1998 and 2007 at a single academic institution as first or senior authors on papers published during their 3-year fellowship and 3 years after completion of their categorical fellowship (n=63, 30 fellows before 2003 and 33 fellows after 2003). The numbers of first- or senior-author fellow publications before and after 2003 were compared. We also collected data on final paediatric cardiology subspecialty career choice. RESULTS There was no difference in the number of fellow first-author publications before and after 2003. Before work-hour restrictions, the mean number of publications per fellow was 2.1 (±2.2), and after work-hour restrictions it was 2.0 (±1.8), (p=0.89). By subspecialty career choice, fellows who select electrophysiology, preventative cardiology, and heart failure always published within the 6-year time period. CONCLUSIONS Since the implementation of work-hour regulations, total number of fellow first-authored publications has not changed. The role of subspecialty choice may play a role in academic productivity of fellows in training.
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Davis MC, Kuhn EN, Agee BS, Oster RA, Markert JM. Implications of transitioning to a resident night float system in neurosurgery: mortality, length of stay, and resident experience. J Neurosurg 2016; 126:1269-1277. [PMID: 27392266 DOI: 10.3171/2016.5.jns152585] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Many neurosurgical training programs have moved from a 24-hour resident call system to a night float system, but the impact on outcomes is unclear. Here, the authors compare length of stay (LOS) for neurosurgical patients admitted before and after initiation of a night float system at a tertiary care training hospital. METHODS The neurosurgical residency at the University of Alabama at Birmingham transitioned from 24-hour call to a night float resident coverage system in July 2013. In this cohort study, all patients admitted to the neurosurgical service for 1 year before and 1 year after this transition were compared with respect to hospital and ICU LOSs, adjusted for potential confounders. RESULTS A total of 4619 patients were included. In the initial bivariate analysis, night float was associated with increased ICU LOS (p = 0.032) and no change in overall LOS (p = 0.65). However, coincident with the transition to a night float system was an increased frequency of resident service transitions, which were highly associated with hospital LOS (p < 0.01) and ICU LOS (p < 0.01). After adjusting for resident service transitions, initiation of the night float system was associated with decreased hospital LOS (p = 0.047) and no change in ICU LOS (p = 0.35). CONCLUSIONS This study suggests that a dedicated night float resident may improve night-to-night continuity of care and decrease hospital LOS, but caution must be exercised when initiation of night float results in increased resident service transitions.
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Affiliation(s)
| | | | | | - Robert A Oster
- Center for Clinical and Translational Sciences, University of Alabama at Birmingham, Alabama
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Kjærgaard J, Sillesen M, Beier-Holgersen R. No Correlation Between Work-Hours and Operative Volumes--A Comparison Between United States and Danish Operative Volumes Achieved During Surgical Residency. JOURNAL OF SURGICAL EDUCATION 2016; 73:461-465. [PMID: 26708491 DOI: 10.1016/j.jsurg.2015.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 10/20/2015] [Accepted: 11/06/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Since 2003, United States residents have been limited to an 80-hour workweek. This has prompted concerns of reduced educational quality, especially inadequate operating exposure. In contrast, the Danish surgical specialty-training program mandates a cap on working hours of 37 per week. We hypothesize that there is no direct correlation between work-hours and operative volume achieved during surgical residency. To test the hypothesis, we compare Danish and US operative volumes achieved during surgical residency training. DESIGN Retrospective comparative study. PARTICIPANTS The data from the US population was extracted from the Accreditation Council for Graduate Medical Education database for General Surgery residents from 2012 to 2013. For Danish residents, a questionnaire with case categories matching the Accreditation Council for Graduate Medical Education categories were sent to all Danish surgeons graduating the national surgical residency program in 2012 or 2013, 54 in total. RESULTS In all, 30 graduated residents (55%) responded to the Danish survey. We found no significant differences in mean total major procedures (1002.4 vs 976.9, p = 0.28) performed during residency training, but comparing average major procedures per year, the US residents achieve significantly more (132.3 vs 195.4, p <0.01). When factoring in differences in time spent in training, this amounts to a weekly average difference of 1.2 cases throughout training. CONCLUSIONS In this study, we find no difference in overall surgical volumes between Danes and US residents during their surgical training. When time in training was accounted for, differences between weekly surgical volumes achieved were minor, indicating a lack of direct correlation between weekly work-hours and operative volumes achievable. Factors other than work-hours seem to effect on operative volumes achieved during training.
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Affiliation(s)
- Jane Kjærgaard
- Department of Surgery, Copenhagen University Hospital, Hillerød, Denmark
| | - Martin Sillesen
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Lin H, Lin E, Auditore S, Fanning J. A Narrative Review of High-Quality Literature on the Effects of Resident Duty Hours Reforms. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2016; 91:140-50. [PMID: 26445081 DOI: 10.1097/acm.0000000000000937] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
PURPOSE To summarize current high-quality studies evaluating the effect and efficacy of resident duty hours reforms (DHRs) on patient safety and resident education and well-being. METHOD The authors searched PubMed and Medline in August 2012 and again in May 2013 for literature (1987-2013) about the effects of DHRs. They assessed the quality of articles using the Medical Education Research Study Quality Instrument (MERSQI) scoring system. They considered randomized controlled trials (RCTs), partial RCTs, and all studies with a MERSQI score ≥ 14 to be "high-quality" methodology studies. RESULTS A total of 72 high-quality studies met inclusion criteria. Most studies showed no change or slight improvement in mortality and complication rates after DHRs. Resident well-being was generally improved, but there was a perceived negative impact on education (knowledge acquisition, skills, and cognitive performance) following DHRs. Eleven high-quality studies assessed the impact of DHR interventions; all reported a neutral to positive impact. Seven high-quality studies assessed costs associated with DHRs and demonstrated an increase in hospital costs. CONCLUSIONS The results of most studies that allow enough time for DHR interventions to take effect suggest a benefit to patient safety and resident well-being, but the effect on the quality of training remains unknown. Additional methodologically sound studies on the impact of DHRs are necessary. Priorities for future research include approaches to optimizing education and clinical proficiency and studies on the effect of intervention strategies on both education and patient safety. Such studies will provide additional information to help improve duty hours policies.
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Affiliation(s)
- Henry Lin
- H. Lin is a pediatric gastroenterologist, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. E. Lin is a gastroenterology fellow, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin. S. Auditore is market segment development manager, American Medical Association, Chicago, Illinois. J. Fanning is chief of membership and resident fellow member-early career psychiatrist officer, American Psychiatric Association, Arlington, Virginia
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13
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Babu R, Thomas S, Hazzard MA, Lokhnygina YV, Friedman AH, Gottfried ON, Isaacs RE, Boakye M, Patil CG, Bagley CA, Haglund MM, Lad SP. Morbidity, mortality, and health care costs for patients undergoing spine surgery following the ACGME resident duty-hour reform. J Neurosurg Spine 2014; 21:502-15. [DOI: 10.3171/2014.5.spine13283] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The Accreditation Council for Graduate Medical Education (ACGME) implemented resident duty-hour restrictions on July 1, 2003, in concern for patient and resident safety. Whereas studies have shown that duty-hour restrictions have increased resident quality of life, there have been mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay (LOS), and charges in patients who underwent spine surgery.
Methods
The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, LOS, and charges by comparing the prereform (2000–2002) and postreform (2005–2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method.
Results
A total of 693,058 patients were included in the study. The overall complication rate was 8.6%, with patients in the postreform era having a significantly higher rate than those in the pre–duty-hour restriction era (8.7% vs 8.4%, p < 0.0001). Examination of hospital teaching status revealed complication rates to decrease in nonteaching hospitals (8.2% vs 7.6%, p < 0.0001) while increasing in teaching institutions (8.6% vs 9.6%, p < 0.0001) in the duty-hour reform era. The DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching institutions to had a significantly greater increase in complications during the postreform era (p = 0.0002). The overall mortality rate was 0.37%, with no significant difference between the pre– and post–duty-hour eras (0.39% vs 0.36%, p = 0.12). However, the mortality rate significantly decreased in nonteaching hospitals in the postreform era (0.30% vs 0.23%, p = 0.0008), while remaining the same in teaching institutions (0.46% vs 0.46%, p = 0.75). The DID analysis to compare the changes in mortality between groups revealed that the difference between the effects approached significance (p = 0.069). The mean LOS for all patients was 4.2 days, with hospital stay decreasing in nonteaching hospitals (3.7 vs 3.5 days, p < 0.0001) while significantly increasing in teaching institutions (4.7 vs 4.8 days, p < 0.0001). The DID analysis did not demonstrate the magnitude of change for each group to differ significantly (p = 0.26). Total patient charges were seen to rise significantly in the post–duty-hour reform era, increasing from $40,000 in the prereform era to $69,000 in the postreform era. The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.55).
Conclusions
The implementation of duty-hour restrictions was associated with an increased risk of postoperative complications for patients undergoing spine surgery. Therefore, contrary to its intended purpose, duty-hour reform may have resulted in worse patient outcomes. Additional studies are needed to evaluate strategies to mitigate these effects and assist in the development of future health care policy.
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Affiliation(s)
- Ranjith Babu
- 1Division of Neurosurgery, Department of Surgery, Duke University Medical Center
| | - Steven Thomas
- 1Division of Neurosurgery, Department of Surgery, Duke University Medical Center
| | - Matthew A. Hazzard
- 1Division of Neurosurgery, Department of Surgery, Duke University Medical Center
| | - Yuliya V. Lokhnygina
- 2Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Allan H. Friedman
- 1Division of Neurosurgery, Department of Surgery, Duke University Medical Center
| | - Oren N. Gottfried
- 1Division of Neurosurgery, Department of Surgery, Duke University Medical Center
| | - Robert E. Isaacs
- 1Division of Neurosurgery, Department of Surgery, Duke University Medical Center
| | - Maxwell Boakye
- 3Department of Neurosurgery, University of Louisville, Kentucky; and
| | - Chirag G. Patil
- 4Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Carlos A. Bagley
- 1Division of Neurosurgery, Department of Surgery, Duke University Medical Center
| | - Michael M. Haglund
- 1Division of Neurosurgery, Department of Surgery, Duke University Medical Center
| | - Shivanand P. Lad
- 1Division of Neurosurgery, Department of Surgery, Duke University Medical Center
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Babu R, Thomas S, Hazzard MA, Friedman AH, Sampson JH, Adamson C, Zomorodi AR, Haglund MM, Patil CG, Boakye M, Lad SP. Worse outcomes for patients undergoing brain tumor and cerebrovascular procedures following the ACGME resident duty-hour restrictions. J Neurosurg 2014; 121:262-76. [PMID: 24926647 DOI: 10.3171/2014.5.jns1314] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT On July 1, 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour restrictions for resident physicians due to concerns for patient and resident safety. Though duty-hour restrictions have increased resident quality of life, studies have shown mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay, and charges in patients who underwent brain tumor and cerebrovascular procedures. METHODS The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, length of stay, and charges by comparing the pre-reform (2000-2002) and post-reform (2005-2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method. RESULTS A total of 90,648 patients were included in the analysis. The overall complication rate was 11.7%, with the rates not significantly differing between the pre- and post-duty hour eras (p = 0.26). Examination of hospital teaching status revealed that complication rates decreased in nonteaching hospitals (12.1% vs 10.4%, p = 0.0004) and remained stable in teaching institutions (11.8% vs 11.9%, p = 0.73) in the post-reform era. Multivariate analysis demonstrated a significantly higher complication risk in teaching institutions (OR 1.33 [95% CI 1.11-1.59], p = 0.0022), with no significant change in nonteaching hospitals (OR 1.11 [95% CI 0.91-1.37], p = 0.31). A DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching hospitals had a significantly greater increase in complications during the post-reform era than nonteaching hospitals (p = 0.040). The overall mortality rate was 3.0%, with a significant decrease occurring in the post-reform era in both nonteaching (5.0% vs 3.2%, p < 0.0001) and teaching (3.2% vs 2.3%, p < 0.0001) hospitals. DID analysis to compare the changes in mortality between groups did not reveal a significant difference (p = 0.40). The mean length of stay for all patients was 8.7 days, with hospital stay decreasing from 9.2 days to 8.3 days in the post-reform era (p < 0.0001). The DID analysis revealed a greater length of stay decrease in nonteaching hospitals than teaching institutions, which approached significance (p = 0.055). Patient charges significantly increased in the post-reform era for all patients, increasing from $70,900 to $96,100 (p < 0.0001). The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.17). CONCLUSIONS The implementation of duty-hour restrictions correlated with an increased risk of postoperative complications for patients undergoing brain tumor and cerebrovascular neurosurgical procedures. Duty-hour reform may therefore be associated with worse patient outcomes, contrary to its intended purpose. Due to the critical condition of many neurosurgical patients, this patient population is most sensitive and likely to be negatively affected by proposed future increased restrictions.
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Affiliation(s)
- Ranjith Babu
- Department of Surgery, Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina
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Ragel BT, Piedra M, Klimo P, Burchiel KJ, Waldo H, McCartney S, Selden NR. An ACGME Duty Hour Compliant 3-Person Night Float System for Neurological Surgery Residency Programs. J Grad Med Educ 2014; 6:315-9. [PMID: 24949139 PMCID: PMC4054734 DOI: 10.4300/jgme-d-13-00172.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 07/15/2013] [Accepted: 01/01/2014] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND In 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted the 24+6-hour work schedule and 80-hour workweek, and in 2011, it enhanced work hour and supervision standards. INNOVATION In response, Oregon Health & Science University's (OHSU) neurological surgery residency instituted a 3-person night float system. METHODS We analyzed work hour records and operative experience for 1 year before and after night float implementation in a model that shortened a combined introductory research and basic clinical neurosciences rotation from 12 to 6 months. We analyzed residents' perception of the system using a confidential survey. The ACGME 2011 work hour standards were applied to both time periods. RESULTS AFTER NIGHT FLOAT IMPLEMENTATION, THE NUMBER OF DUTY HOUR VIOLATIONS WAS REDUCED: 28-hour shift (11 versus 235), 8 hours off between shifts (2 versus 20), 80 hours per week (0 versus 17), and total violations (23 versus 275). Violations increased only for the less than 4 days off per 4-week interval rule (10 versus 3). No meaningful difference was seen in the number of operative cases performed per year at any postgraduate year (PGY) training level: PGY-2 (336 versus 351), PGY-3 (394 versus 354), PGY-4 (803 versus 802), PGY-5 (1075 versus 1040), PGY-7 (947 versus 913), and total (3555 versus 3460). Residents rated the new system favorably. CONCLUSIONS To meet 2011 ACGME duty hour standards, the OHSU neurological surgery residency instituted a 3-person night float system. A nearly complete elimination of work hour violations did not affect overall resident operative experience.
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Who's covering our loved ones: surprising barriers in the sign-out process. Am J Surg 2013; 205:77-84. [DOI: 10.1016/j.amjsurg.2012.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 05/21/2012] [Accepted: 05/21/2012] [Indexed: 11/17/2022]
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Trends in operative experience of pediatric surgical residents in the United States and Canada. J Pediatr Surg 2013; 48:88-94. [PMID: 23331798 DOI: 10.1016/j.jpedsurg.2012.10.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Accepted: 10/13/2012] [Indexed: 11/24/2022]
Abstract
PURPOSE Expansion of the number of training programs in pediatric surgery occurred from 2003 through 2010. We sought to determine the effect of program expansion on case volume and distribution of operative experience. METHODS Public domain data on pediatric surgery resident summary statistics available from the Accreditation Council for Graduate Medical Education (ACGME) from July 2003 through June 2010 were analyzed. Total case volume as primary surgeon or teaching assistant, mean case volume per resident, standard deviation, mode, minimum, and maximum number of cases per resident were evaluated. Mean total cases per resident, minimally invasive laparoscopic and thoracoscopic cases, and requisite cases as defined by the ACGME categories of: tumor, important pediatric surgical, and neonatal cases were analyzed by a Cuzick Wilcoxon-type nonparametric trend statistic using a significance level of 0.05. Skew was assessed by Pearson coefficient with levels of -0.5 to 0.5 defining a parametric distribution. RESULTS The number of pediatric surgical training residents increased by 42% during the years reported, from 24 to 34. No statistically significant difference was found in the mean number of total cases or requisite cases per resident. The mean volume of minimally invasive procedures increased significantly. Case volume per resident was non-parametrically distributed with increasing positive skew over time. CONCLUSIONS The increase in number of pediatric surgical resident training positions has not adversely affected overall operative experience or exposure to highly specialized requisite cases, on average. The increasing positive skew of total and index cases, however, suggests that variability between programs in case exposure is increasing over time.
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Fargen KM, Tomei KL. Duty hour reform through the eyes of neurological surgery residents. J Grad Med Educ 2012; 4:415-6. [PMID: 24294415 PMCID: PMC3546568 DOI: 10.4300/jgme-d-12-00113.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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