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

Patient Surgical Outcomes When Surgery Residents Are the Primary Surgeon by Intensity of Surgical Attending Supervision in Veterans Affairs Medical Centers

Objective

Using health records from the Department of Veterans Affairs (VA), the largest healthcare training platform in the United States, we estimated independent associations between the intensity of attending supervision of surgical residents and 30-day postoperation patient outcomes.

Background

Academic leaders do not agree on the level of autonomy from supervision to grant surgery residents to best prepare them to enter independent practice without risking patient outcomes.

Methods

Secondary data came from a national, systematic 1:8 sample of n = 862,425 teaching encounters where residents were listed as primary surgeon at 122 VA medical centers from July 1, 2004, through September 30, 2019. Independent associations between whether attendings had scrubbed or not scrubbed on patient 30-day all-cause mortality, complications, and 30-day readmission were estimated using generalized linear-mixed models. Estimates were tested for any residual confounding biases, robustness to different regression models, stability over time, and validated using moderator and secondary factors analyses.

Results

After accounting for potential confounding factors, residents supervised by scrubbed attendings in 733,997 nonemergency surgery encounters had fewer deaths within 30 days of the operation by 14.2% [0.3%, 29.9%], fewer case complications by 7.9% [2.0%, 14.0%], and fewer readmissions by 17.5% [11.2%, 24.2%] than had attendings not scrubbed. Over the 15 study years, scrubbed surgery attendings may have averted an estimated 13,700 deaths, 43,600 cases with complications, and 73,800 readmissions.

Conclusions

VA policies on attending surgeon supervision have protected patient safety while allowing residents in selected teaching encounters to have limited autonomy from supervision.

We Need to Do Better: A Scoping Review of Wellness Programs In Surgery Residency

OBJECTIVE

Burnout, depression, and fatigue are common among surgical residents. Most published wellness studies in surgery only focus on a cross-sectional view of attitudes and perceptions around wellness in training. While much of this literature calls for interventions and presents strategies for improving resident well-being, there is a paucity of published wellness initiatives, and even fewer with programmatic evaluation.

DESIGN

A scoping review was designed to address: (1) What wellness initiatives are used in surgery residency programs? (2) Which wellness domains do these programs address? and (3) How are program outcomes evaluated? A formal literature search was conducted using PubMed, Embase, and Scopus databases to identify English-language studies conducted in the United States that described wellness-focused initiatives for surgery residents. Two authors independently screened all abstracts and full texts for inclusion. Data were extracted including wellness domain(s) and outcomes evaluation methods with associated Kirkpatrick level(s) (1-reaction, 2-learning, 3-behavior, 4-results). Study quality was examined using the medical education research study quality index (MERSQI) score.

RESULTS

A total of 2237 abstracts were screened with 115 full texts reviewed for eligibility. Fifty-one studies were included in the final analysis, representing 39 distinct wellness programs. The most common domains of wellness addressed were emotional (19/39, 48.7%), occupational (17/39, 43.6%), and physical (16/39, 41.0%). Of the 51 studies reviewed, 8 (15.7%) did not conduct any program evaluation, 27 (52.9%) evaluated level 1, 30 (58.8%) evaluated level 2, 3 (5.9%) evaluated level 3, and none evaluated level 4 outcomes. The mean MERSQI score was 9.16 (SD 1.8).

CONCLUSIONS

Wellness is an established problem in surgical training. This review reveals a small number of published wellness interventions and even fewer that incorporate programmatic evaluation at the level of behavior and results change. Effective change will require rigorous and deliberate programming that addresses multiple domains and evaluation levels.

The Changing Environment in Postgraduate Education in Orthopedic Surgery and Neurosurgery and Its Impact on Technology-Driven Targeted Interventional and Surgical Pain Management: Perspectives from Europe, Latin America, Asia, and The United States

Personalized care models are dominating modern medicine. These models are rooted in teaching future physicians the skill set to keep up with innovation. In orthopedic surgery and neurosurgery, education is increasingly influenced by augmented reality, simulation, navigation, robotics, and in some cases, artificial intelligence. The postpandemic learning environment has also changed, emphasizing online learning and skill- and competency-based teaching models incorporating clinical and bench-top research. Attempts to improve work-life balance and minimize physician burnout have led to work-hour restrictions in postgraduate training programs. These restrictions have made it particularly challenging for orthopedic and neurosurgery residents to acquire the knowledge and skill set to meet the requirements for certification. The fast-paced flow of information and the rapid implementation of innovation require higher efficiencies in the modern postgraduate training environment. However, what is taught typically lags several years behind. Examples include minimally invasive tissue-sparing techniques through tubular small-bladed retractor systems, robotic and navigation, endoscopic, patient-specific implants made possible by advances in imaging technology and 3D printing, and regenerative strategies. Currently, the traditional roles of mentee and mentor are being redefined. The future orthopedic surgeons and neurosurgeons involved in personalized surgical pain management will need to be versed in several disciplines ranging from bioengineering, basic research, computer, social and health sciences, clinical study, trial design, public health policy development, and economic accountability. Solutions to the fast-paced innovation cycle in orthopedic surgery and neurosurgery include adaptive learning skills to seize opportunities for innovation with execution and implementation by facilitating translational research and clinical program development across traditional boundaries between clinical and nonclinical specialties. Preparing the future generation of surgeons to have the aptitude to keep up with the rapid technological advances is challenging for postgraduate residency programs and accreditation agencies. However, implementing clinical protocol change when the entrepreneur-investigator surgeon substantiates it with high-grade clinical evidence is at the heart of personalized surgical pain management.

Simulation-Based Mastery Learning to Teach Distal Radius Fracture Reduction

INTRODUCTION

Distal radius fractures are common orthopedic injuries managed in emergency departments. Simulation-based mastery learning is widely recognized to improve provider competence for bedside procedures but has not been studied to teach fracture management. This study evaluated the effectiveness of a simulation-based mastery learning curriculum to teach distal radius fracture reduction to novice orthopedic surgery and emergency medicine residents.

METHODS

We created a novel mastery learning checklist using the Mastery Angoff method of standard setting, paired with a new simulation model designed for this project, to teach orthopedic surgery and emergency medicine interns (N = 22) at the study site. Orthopedic surgery and emergency medicine faculty members participated in checklist development, curriculum design, and implementation. Training included just-in-time asynchronous education with a readiness assessment test, in-classroom expert demonstration, and deliberate practice with feedback. Residents completed a pretest/posttest skills examination and a presurvey/postsurvey assessing procedural confidence.

RESULTS

Standard setting resulted in a 41-item checklist with minimum passing score of 37/41 items. All participants met or surpassed the minimum passing score on postexamination. Postsurvey confidence levels were significantly higher than presurvey in all aspects of the distal radius fracture procedure (P < 0.05).

CONCLUSIONS

This study demonstrated that a simulation-based mastery learning curriculum improved skills and confidence performing distal radius fracture reductions for orthopedic surgery and emergency medicine interns. Future planned studies include curriculum testing across additional institutions, examination of clinical impact, and application of mastery learning for other orthopedic procedures.

Assessment of Occupational Stress Among Oral and Maxillofacial Surgeons and Residents in Saudi Arabia: A Cross-Sectional Study

PURPOSE

Considering the important role of oral and maxillofacial surgeons in healthcare services and the stressful nature of their job, this study aimed to assess the occupational stress among oral and maxillofacial surgeons and residents in Saudi Arabia.

MATERIALS AND METHODS

Cross-sectional questionnaires were developed, and they included the perceived stress scale and questions about potential sources of stress. A sample size of 180 was determined using a 0.05 level of significance and a precision of ±8%. The survey was distributed using a consecutive non-random sampling method to all oral and maxillofacial surgeons and residents in all regions in Saudi Arabia from May to December 2019.

RESULTS

One hundred and seventy-two responses were received. Males were the predominant gender. The perceived stress scale revealed a moderate stress level among surgeons and residents. However, residents had a significantly higher score (P = 0.005). Increased working days were significantly associated with higher stress levels (P = 0.006). Long on-call periods were significantly and positively correlated with increased stress levels among residents since their work schedule was not flexible (P = 0.000). The majority of surgeons and residents believe that they have unconducive and stressful work environments and that working as a maxillofacial surgeon is stressful.

CONCLUSION

The study results suggest that there is increased occupational stress among oral and maxillofacial surgeons and residents in Saudi Arabia. This study highlights the need for stress management programs to minimize stress factors at the workplace and to ensure a healthy working environment for the practitioners.

The prevalence and effects of on-call stepdown on orthopaedic registrar training: the North West trainees' perspective

INTRODUCTION

Safe staffing levels are increasingly being threatened by gaps in rotas. When a gap occurs in junior grade on-call rotas the orthopaedic registrar needs to step down and undertake the role of both junior and middle-grade doctor. This increased responsibility could compromise the safety and wellbeing of patients and doctors. This study quantifies the prevalence and effects for trainees of stepdown while on call.

MATERIALS AND METHODS

An anonymous online and paper survey of trainees was conducted. The primary outcomes were the prevalence of stepdown in trainees' experience, the effects of stepdown on trainees and patients, and the overall impact on training and morale.

RESULTS

The response rate was 93% (n = 51). Of the total, 55% of trainees had experienced stepdown, which occurred a minimum of 84 times, statistically more frequently for expected absences rather than unexpected absences (p = 0.002). Of the trainees who stepped down, 64% felt pressure to do so from seniors and 79% from hospital management. Some 50% of trainees felt that step down was managed in an unsafe manner; 40% of trainees stated that stepdown impacted on their own personal safety and 50% of trainees lost a training opportunity. Overall, 57% of trainees considered that stepdown and rota gaps affected their morale negatively. In 85% of cases there were no issues that resulted in patient harm.

CONCLUSION

The survey results suggest that stepdown is common and it does impact negatively upon registrar training, safety and morale. Patient safety overall seems to be well protected.

The Effects of 24-Hour Neurosurgical Call on Fine Motor Dexterity, Cognition, and Mood

Background: Concerns regarding the effects of fatigue on physician performance and quality of life lead to the implementation of duty hour restrictions for residents by the Accreditation Council for Graduate Medical Education (ACGME). These restrictions have been met by strong criticism from the neurosurgical community. This is partly due to a lack of objective evidence that fatigue results in decrements in professional function in neurological surgeons. There is also concern that the restrictions have diminished clinical and operative experience as well as the development of professional responsibility in residency.

Objective: To evaluate whether 24-hour neurosurgical call has an objective impact on fine motor dexterity, cognitive thinking skills, and mental well-being.

Methods: Subjects were tested before and after taking 24 hours of neurosurgical call. We evaluated fine motor dexterity using the Vienna Test System Motor Performance Series, cognitive thinking abilities using a battery of paper-pencil neuropsychological tests, and mental well-being using the Profile of Mood States. 

Results: A total of 27 subjects were included in this study, 12 seasoned to neurosurgical call and 15 naive to neurosurgical call. The seasoned subjects demonstrated no statistically significant change in performance after call on any of the tests for fine motor dexterity or cognitive thinking abilities. The nonseasoned subjects demonstrated multiple decrements in fine motor dexterity and cognitive thinking abilities after taking call. In the Motor Performance Series, they had a statistically significant decrease in the speed of untargeted movements in the nondominant hand during the tapping test (p = 0.002), and a decline in the precision of fine motor movements and information processing as evidenced by an increase in the number of errors of the dominant hand in the line tracking test (p = 0.014). There was a statistically significant decline in their immediate memory during Hopkins Verbal Learning Test (p = 0.025), and complex attention, mental flexibility, and visual-motor speed in the Trail Making Test (p = 0.03). The Profile of Mood States found no difference in feelings of anger (p = 0.54), tension (p = 0.358), or depression (p = 0.65). There were increased feelings of confusion (p < 0.001) and decreased feelings of vigor (p < 0.001) and friendliness (p = 0.001). Nonseasoned subjects had an increase in total mood disturbance (p = 0.012) but seasoned subjects did not (p = 0.083). 

Conclusion: Our results suggest that fatigue-induced decrements in professional function can be ameliorated by experience with prolonged duty hours. In contrast to nonseasoned subjects, those who were conditioned to 24-hour neurosurgical call demonstrated resilience in fine motor dexterity and cognitive thinking skills, and exhibited no change in total mood disturbance. An argument can be made that we are turning the neurosurgical training paradigm upside down with the current ACGME duty hour restrictions. 

Impact of work hours and sleep on well-being and burnout for physicians-in-training: the Resident Activity Tracker Evaluation Study

OBJECTIVE

The Resident Activity Tracker Evaluation (RATE) is a prospective observational study evaluating the impact of work hours, sleep and physical activity on resident well-being, burnout and job satisfaction.

BACKGROUND

Physician burnout is common and its incidence is increasing. The impact of work hours and sleep on resident well-being and burnout remains elusive. Activity trackers are an innovative tool for measuring sleep and physical activity.

METHODS

Residents were recruited from (i) general surgery and orthopaedics (SURG), (ii) internal medicine and neurology (MED) and (iii) anaesthesia and radiology (RCD). Groups 1 and 2 do not enforce restrictions on the duration of being on-call, and group 3 had restricted the duration of being on-call to 12 hours. Participants wore FitBit trackers for 14 days. Total hours worked, daily sleep, sleep on-call and daily steps were recorded. Participants completed validated surveys assessing self-reported well-being (Short-Form Health Survey), burnout (Maslach Burnout Inventory), and satisfaction with medicine.

RESULTS

Surgical residents worked the most hours per week, followed by medical and RCD residents (SURG, 84.3 hours, 95% CI, 80.2-88.5; MED, 69.2 hours, 95% CI, 65.3-73.2; RCD, 52.2 hours, 95% CI, 48.2-56.1; p < 0.001). Surgical residents obtained fewer hours of sleep per day (SURG, 5.9 hours, 95% CI, 5.5-6.3; MED, 6.9 hours, 95% CI, 6.5-7.3; RCD, 6.8 hours, 95% CI, 5.6-7.2; p < 0.001). Nearly two-thirds of participants (61%) scored high burnout on the Maslach depersonalisation subscore. Total steps per day and well-being, burnout and job satisfaction were comparable between groups. Total hours worked, daily sleep and steps per day did not predict burnout or well-being.

CONCLUSIONS

Work hours and average daily sleep did not affect burnout. Physical activity did not prevent burnout. Work hour restrictions may lead to increased sleep but may not affect resident burnout or well-being.

Understanding the Multidimensional Effects of Resident Duty Hours Restrictions: A Thematic Analysis of Published Viewpoints in Surgery

PURPOSE

Individuals representing various surgical disciplines have expressed concerns with the impact of resident duty hours (RDH) restrictions on resident education and patient outcomes. This thematic review of published viewpoints aimed to describe the effects of these restrictions in surgery.

METHOD

The authors conducted a qualitative systematic review of non-research-based literature published between 2003 and 2015. Articles were included if they focused on the RDH restrictions in surgery and resident wellness, health promotion, resident safety, resident education and/or training, patient safety, medical errors, and/or heterogeneity regarding training or disciplines. A thematic analysis approach guided data extraction. Contextual data were abstracted from the included articles to aid in framing the identified themes.

RESULTS

Of 1,482 identified articles, 214 were included in the review. Most were from authors in the United States (144; 67%) and focused on the 80-hour workweek (164; 77%). The emerging themes were organized into three overarching categories: (1) impact of the RDH restrictions, (2) surgery has its own unique culture, and (3) strategies going forward. Published opinions suggested that RDH restrictions alone are insufficient to achieve the desired outcomes and that careful consideration of the surgical training model is needed to maintain the integrity of educational outcomes.

CONCLUSIONS

Opinions from the surgical community highlight the complexity of issues surrounding the RDH restrictions and suggest that recent changes are not achieving all the desired outcomes and have resulted in unintended outcomes. From the perceptions of the various stakeholders in surgical education studied, areas for new policies were identified.

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.

Teaching the Basics: Development and Validation of a Distal Radius Reduction and Casting Model

BACKGROUND

Approximately one-third of reduced pediatric distal radius fractures redisplace, resulting in further treatment. Two major modifiable risk factors for loss of reduction are reduction adequacy and cast quality. Closed reduction and immobilization of distal radius fractures is an Accreditation Council for Graduate Medical Education residency milestone. Teaching and assessing competency could be improved with a life-like simulation training tool.

QUESTIONS/PURPOSES

Our goal was to develop and validate a realistic distal radius fracture reduction and casting simulator as determined by (1) a questionnaire regarding the "realism" of the model and (2) the quantitative assessments of reduction time, residual angulation, and displacement.

METHODS

A distal radius fracture model was created with radiopaque bony segments and articulating elbows and shoulders. Simulated periosteum and internal deforming forces required proper reduction and casting techniques to achieve and maintain reduction. The forces required were estimated through an iterative process through feedback from experienced clinicians. Embedded monofilaments allowed for quantitative assessment of residual displacement and angulation through the use of fluoroscopy. Subjects were asked to perform closed reduction and apply a long arm fiberglass cast. Primary performance variables assessed included reduction time, residual angulation, and displacement. Secondary performance variables consisted of number of fluoroscopic images, casting time, and cast index (defined as the ratio of the internal width of the forearm cast in the sagittal plane to the internal width in the coronal plane at the fracture site). Subject grading was performed by two blinded reviewers. Interrater reliability was nearly perfect across all measurements (intraclass correlation coefficient range, 0.94-0.99), thus disagreements in measurements were handled by averaging the assessed values. After completion the participants answered a Likert-based questionnaire regarding the realism of simulation. Eighteen participants consented to participate in the study (eight attending pediatric orthopaedic surgeons, six junior residents, four senior residents). The performances of junior residents (Postgraduate Year [PGY] 1-2), senior residents (PGY 3-5), and attending surgeons were compared using one-way ANOVA with Tukey's-adjusted pairwise comparisons.

RESULTS

The majority of participants (15 of 18) felt that the model looked, felt, and moved like a human forearm. All participants strongly agreed that the model taught the basic steps of fracture reduction and should be implemented in orthopaedic training. Attending surgeons reduced fractures in less time than junior residents (60 ± 27 seconds versus 460 ± 62 seconds; mean difference, 400 seconds; 95% CI, 335-465 seconds; p < 0.001). Residual angulation was greater for junior residents when compared with attending surgeons on AP (7° ± 5° versus 0.7° ± 0.9°; mean difference, 6.3°; 95% CI, 3°-11°; p = 0.003) and lateral (27° ± 7° versus 7° ± 5°; mean difference, 20°; 95% CI, 13°-27°; p = 0.001) radiographs. Similarly, residual displacement was greater for junior residents than either senior residents (mean difference, 16 mm; 95% CI, 2-34 mm; p = 0.05) or attending surgeons (mean difference, 15 mm; 95% CI, 3-27 mm; p = 0.02) on lateral images. There were no differences identified in secondary performance variables (number of fluoroscopic images, casting time, and cast index) between groups.

CONCLUSIONS

This is the first distal radius fracture reduction model to incorporate an elbow and shoulder and allow quantitative assessment of the fracture reduction. This simulator may be useful in an orthopaedic resident training program to help them reach a defined minimum level of competency. This simulator also could easily be integrated in other accreditation and training programs, including emergency medicine.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Core Concepts: Orthopedic Intern Curriculum Boot Camp

Orthopedic surgical interns must gain a broad array of clinical skills in a short time. However, recent changes in health care have limited resident-patient exposures. With the reported success of simulation training in the surgical literature, the American Board of Orthopaedic Surgery (ABOS) and Residency Review Committee for Orthopaedic Surgery have required that surgical simulation training be a component of the intern curricula in orthopedic surgical residencies. This study examined the short-term effectiveness of an orthopedic "intern boot camp" covering 7 of 17 simulation training concept modules published by the ABOS. Eight orthopedic post-graduate year 1 (PGY-1) residents (study group) completed a structured 3-month curriculum and were compared with 7 post-graduate year 2 (PGY-2) residents (comparison group) who had just completed their orthopedic surgical internship. Seven core skills were assessed using both task-specific and global rating scales. The PGY-1 residents demonstrated a statistically significant improvement in all 7 modules with respect to their task-specific pre-test scores: sterile technique (P=.001), wound closure (P<.001), knot tying (P=.017), casting and splinting (P<.001), arthrocentesis (P=.01), basics of internal fixation (P<.001), and compartment syndrome evaluation (P=.004). After the camp, PGY-1 and -2 scores in task-specific measures were not significantly different. A 3-month simulation-based boot camp instituted early in orthopedic internship elevated a variety of clinical skills to levels exhibited by PGY-2 residents.

The Importance of Fostering Ownership During Medical Training

There is a need to consider the impact of the new resident-hours regulations on the variety of aspects of medical education and patient care. Most existing literature about this subject has focused on the role of fatigue in resident performance, education, and health care delivery. However, there are other possible consequences of these new regulations, including a negative impact on decision ownership. Our main assumption of is that increased shift work in medicine can decrease ownership of treatment decisions and impact negatively on quality of care. We review some potential components of decision ownership in treatment context and suggest possible ways in which the absence of decision ownership may decrease the quality of medical decision making. The article opens with the definition of decision ownership and the overview of some contextual factors that may contribute to the development of ownership in medical residency. The following section discusses decision ownership in medical care from the perspective of "diffusion of responsibility." We question the quality of choices made within narrow decisional frames. We also compare isolated and interrelated choices, assuming that residents make more isolated decisions during their shifts. Lastly, we discuss the consequences of decreased decision ownership impacting the delivery of health care.

The Impact of the 2011 Accreditation Council for Graduate Medical Education Duty Hour Reform on Quality and Safety in Trauma Care

BACKGROUND

In 2011, the ACGME limited duty hours for residents. Although studies evaluating the 2011 policy have not shown improvements in general measures of morbidity or mortality, these outcomes might not reflect changes in specialty-specific practice patterns and secondary quality measures.

STUDY DESIGN

All trauma admissions from July 2009 through June 2013 at an academic Level I trauma center were evaluated for 5 primary outcomes (eg, mortality and length of stay), and 10 secondary quality measures and practice patterns (eg, operating room [OR] visits). All variables were compared before and after the reform (July 1, 2011). Piecewise regression was used to study temporal trends in quality.

RESULTS

There were 11,740 admissions studied. The reform was not strongly associated with changes in any primary outcomes except length of stay (7.98 to 7.36 days; p = 0.01). However, many secondary quality metrics changed. The total number of OR and bedside procedures per admission (6.72 to 7.34; p < 0.001) and OR visits per admission (0.76 to 0.91; p < 0.001) were higher in the post-reform group, representing an additional 9,559 procedures and 1,584 OR visits. Use of minor bedside procedures, such as laboratory and imaging studies, increased most significantly.

CONCLUSIONS

Although most major outcomes were unaffected, quality of care might have changed after the reform. Indeed, a consistent change in resource use patterns was manifested by substantial post-reform increases in measures such as bedside procedures and OR visits. No secondary quality measures exhibited improvements strongly associated with the reform. Several factors, including attending oversight, might have insulated major outcomes from change. Our findings show that some less-commonly studied quality metrics related to costs of care changed after the 2011 reform at our institution.

Medial Epicondyle Fractures in Children and Adolescents: Shifting Care from General Hospitals to Children's Hospitals?

OBJECTIVES

To determine if there is a shift in the treatment of children with medial epicondyle fractures toward children's hospitals, and to explore potential confounders of any observed effect.

STUDY DESIGN

The Healthcare Cost and Utilization Project Kids' Inpatient Database was used to examine the epidemiology of medial epicondyle fractures, particularly with attention to whether they were admitted to a general hospital or a children's hospital (defined as free-standing children's hospitals, specialty children's hospitals, and children's units within general hospitals). Age and insurance payer status were also collected and evaluated as potential confounders.

RESULTS

The proportion of medial epicondyle hospital discharges from children's hospitals increased (from 29%-46%; P < .001), and the proportion of discharges from general hospitals declined over the study period (from 71%-42%; P < .001). Age and insurance payer status both remained consistent throughout the study period and did not contribute to this finding.

CONCLUSIONS

This study demonstrates an increase in the proportion of discharges for pediatric medial epicondyle fractures from children's hospitals. Although this finding is likely multifactorial, it may represent increasing subspecialization and increasing medical liability when treating children. Children's hospitals should identify those conditions which will continue to increase in number and consider constructing clinical pathways in order to optimize delivery of care and resource utilization.

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.

Development and validation of a basic arthroscopy skills simulator

PURPOSE

The purpose of our study was to develop a low-fidelity surgical simulator for basic arthroscopic skills training, with the goal of creating a pretrained novice ready with the basic skills necessary for all joint arthroscopic procedures.

METHODS

A panel of education, arthroscopy, and simulation experts designed and evaluated a basic arthroscopic skills training and testing box. Task deconstruction was used to create 2 modules, which incorporate core skills common to all arthroscopic procedures. Core metrics measured were time to completion, number of trials to steady state, and number of errors. Face validity was evaluated using a questionnaire. Construct validity was examined by comparing 8 medical students with 8 expert orthopaedic surgeons.

RESULTS

Surgeons were faster than students on both module 1 (P = .0013), simulating triangulation skills, and module 2 (P = .0190) simulating object manipulation skills. Surgeons demonstrated fewer errors (6.9 errors versus 28.1; P = .0073). All surgeons were able to demonstrate steady state (i.e., perform 2 trials that were within 10% of each other for time to completion and errors) on both modules within 3 trials on each module. Only 2 novices were able to demonstrate steady state on either module, and both did so within 3 trials. Furthermore, face validity of the skills trainer was shown by the expert arthroscopists.

CONCLUSIONS

We describe a basic arthroscopy skills simulator that has face and construct validity. Our expert panel was able to design a simulator that differentiated between experienced arthroscopists and novices.

CLINICAL RELEVANCE

Surgical simulation is an important part of efficient surgical education. This simulator shows good construct and face validity and provides a low-fidelity option for teaching the entry-level arthroscopist.

Surgical training using three-dimensional simulation in placement of cervical lateral mass screws: a blinded randomized control trial

BACKGROUND CONTEXT

The skills and knowledge that residents have to master has increased, yet the amount of hours that the residents are allowed to work has been reduced. There is a strong need to improve training techniques to compensate for these changes. One approach is to use simulation-training methods to shorten the learning curve for surgeons in training.

PURPOSE

To analyze the effect of surgical training using three-dimensional (3D) simulation on the placement of lateral mass screws in the cervical spine on either cadavers or sawbones.

STUDY DESIGN

A blinded randomized control study.

METHODS

Fifteen orthopedic residents, postgraduate year (PGY) 1 to 6, were asked to simulate Magerl lateral mass screw trajectories from C3-C7 on cadavers using a navigated drill guide, but with no feedback as to the actual trajectory within the bone (Baseline 1). This was repeated to determine baseline accuracy (Baseline 2). They were then randomized into three groups: Group 1, control, did not receive any training, whereas Groups 2 and 3 received 3D navigational feedback as to the intended drill trajectory on sawbones and cadavers, respectively. All three groups then performed final simulated drilling (final test). All 3D images were deidentified and reviewed by a blinded single fellowship-trained orthopedic spine surgeon. Each image/screw was measured for the starting site, caudad/cephalad angle, and medial/lateral angle to determine trajectory accuracy.

RESULTS

The aggregate mean difference from a perfect screw was compiled for each session for each group. A negative difference shows improvement, whereas a positive difference shows regression. The difference between final test and Baseline 1 in the control group was 2.4°, suggesting regression. In contrast, the differences for groups sawbone and cadaver were -8.2° and -7.2°, respectively, suggesting improvement. When comparing the difference in aggregate sum angle for the sawbones and cadaver groups with the control group, the difference was statistically significant (p<.0001).

CONCLUSIONS

Training with 3D navigation significantly improved the ability of orthopedic residents to properly drill simulated lateral mass screws. As such, training with 3D navigation may be a useful adjunct in resident surgical education.