The 80-hour work week: Will we have less-experienced graduating surgeons?

doi:10.1016/j.cursur.2004.06.016

Current Surgery

Volume 61, Issue 6, November–December 2004, Pages 612-615

https://doi.org/10.1016/j.cursur.2004.06.016 Get rights and content

Objective

Our primary concern when modifying the Mount Carmel Medical Center surgical residency to comply with the “80-hour work week” was the effect on operative experience. Our goal was to measure the impact that work-hour restrictions have on operative volumes and to evaluate the potential benefit of a night rotation to minimize the number of “lost operations.”

Design

Categorical surgical residents (PGY I-IV) recorded missed surgical procedures on post-call days from September 1, 2002 to March 31, 2004. The data collection is split between the pre-night rotation (September 1, 2002 to March 31, 2003) and post-night rotation (April 1, 2003 to March 31, 2004) periods. The post-night rotation period is further divided to account for the end of the academic year. Previous graduate operative logs were reviewed for comparison.

Setting

Mount Carmel Health System is a tertiary referral, community-based hospital in Columbus, Ohio.

Participants

Categorical general surgery residents (Postgraduate Years I to V).

Results

In the 7-month period, extending from September 1, 2002 to March 31, 2003, the average number of missed cases for successive levels was PGY I: 21, PGY II: 31, PGY III: 26, and PGY IV: 40. From April 1, 2003 to June 30, 2003, the average number of missed cases for successive levels was PGY I: 3, PGY II: 7, PGY III: 5, and PGY IV: 6. From July 1, 2003 to March 31, 2004, the average number of missed cases for successive levels was PGY I: 34, PGY II: 8, PGY III: 14, and PGY IV: 30. Before the implementation of a night rotation, residents were projected to miss an average of 202 operations over 4 years. After implementation of a night rotation, the projected loss would drop to 107 operations over 4 years.

Conclusions

Work-hour restrictions result in a significant decrease in operative experience. This detriment can be partially alleviated with the institution of a night rotation to better regulate in-house call.

Introduction

The Accreditation Council for Graduate Medical Education (ACGME) instituted the “80-hour work week” on July 1, 2003. Despite preemptive notice, surgical residencies have had difficulty incorporating the regulations while concomitantly maintaining solid resident education. The ramifications of hour restrictions are complicated with regard to financial factors, work force reductions, and the provision of a constricting environment to train general surgeons.

The major problem with the adjustment to the hour restrictions is not so much limiting residents to 80 hours per week as it is molding those hours into the time frames required. Challenges are evident in situations when residents are required to leave the hospital in the face of educational opportunities, such as family discussions, attending bedside rounds, and didactic conferences. Through the trials of adaptation to the 80-hour work week, it becomes clear that maintaining the production of well-rounded, mature, and adept general surgeons is the most critical initiative.

We have been concerned with the effect of hour restrictions on resident operative volume. Prospective trials that address this issue have not been published despite its centrality to the maturation of general surgeons. We hypothesized that surgical residents at Mount Carmel would miss a significant number of operations with the implementation of the 80-hour work week. In addition, we anticipated that the implementation of a night rotation would decrease the operative loss.

Section snippets

Materials and methods

We began compliance with the ACGME regulations on July 1, 2002, and data collection began on September 1, 2002. Postgraduate Year I to IV residents recorded operations that they would have performed on post in-house call days from September 1, 2002 to March 31, 2004. The Mount Carmel intranet was used to obtain data. Recorded operations were categorical cases in which the resident would have participated as the junior surgeon or rarely as first assistant.

From September 1, 2002 to March 30,

Results

The average number of missed operations for successive postgraduate years is displayed in TABLE 1, TABLE 2, TABLE 3. The data for the pre-night rotation (7-month period) were extrapolated to 12 months by dividing the number of missed operations by 7 months and multiplying the result by 12 months (Table 1). The post-night rotation is divided to account for the end of the academic year (Table 2). The number of missed operations for pre- and post-night rotation periods are displayed (Table 3). The

Discussion

The Accreditation Council for Graduate Medical Education’s institution of the 80-hour work week has set forth significant challenges for general surgery residency programs across the United States. The immediate challenge facing programs stems solely from a decrease in work force. It becomes painstakingly clear that many resident obligations are “service-oriented” and can be covered by nonphysician practitioners. Redefining resident responsibilities and clarifying which of these

Acknowledgments

The authors acknowledge the editorial assistance of Lisa Farina.

References (4)

W. Silen
Crisis in surgical education
J Am Coll Surg
(2001)
J.C. Mayberry
Residency reform Halstead-style
J Am Coll Surg
(2003)

There are more references available in the full text version of this article.

Cited by (53)

Randomized trial of the effect of video training on residents' surgical skills in facial skin reconstructive surgery: A SQUIRE study
2022, Annales Francaises d'Oto-Rhino-Laryngologie et de Pathologie Cervico-Faciale
L’objectif de cette étude était d’évaluer l’impact des vidéos de formation chirurgicale des internes en chirurgie de reconstruction cutanée du visage.
Cet essai randomisé conduit en France, intervenait auprès d’internes en chirurgie de la tête et du cou. Un site internet était réalisé contenant des vidéos de formation en chirurgie de reconstruction cutanée de la face. Les internes sélectionnés étaient accueillis à l’école de Chirurgie de Paris pour réaliser des dissections de lambeaux cutanés de la face. Ils étaient randomisés en deux groupes, certains avaient reçu avant la dissection un cours classique, d’autres avaient reçu un cours classique et une vidéo du lambeau à réaliser (groupe « pas de vidéo » ou « vidéo »). Chaque interne réalisait 4 lambeaux du visage et était noté en aveugle pendant la dissection. L’objectif principal de l’étude correspondait à noter une différence entre les deux groupes à l’aide de la note sur 15. La rédaction de cet article respectait les critères SQUIRE-EDU (Standards for QUality Improvement Reporting Excellence in Education).
L’étude incluait 18 internes. Les notes sur 15 dans le groupe « vidéo » étaient significativement plus élevées que dans le groupe « pas de vidéo » (6 [4 : 9] vs 10 [9 : 12] ; p < 0,001). Cette différence était retrouvée pour les objectifs secondaires : les internes qui n’avaient pas visualisé la vidéo du lambeau avant dissection avaient plus demandé d’aides que les autres (3 [2 : 4] vs 1 [1 : 2] p < 0,001). Les analyses en sous-groupe concernant l’année d’étude de l’interne ou les 4 lambeaux manquaient de puissance pour montrer des résultats significatifs.
Les vidéos semblaient améliorer les performances des internes en chirurgie lors de dissections. Ces résultats étaient cependant difficilement transposables à des conditions cliniques réelles. Ils devraient être validés par une étude plus large et évaluant les performances des internes lors d’interventions chirurgicales.
Randomized trial of the effect of video training on residents’ surgical skills in facial skin reconstructive surgery: A SQUIRE study
2022, European Annals of Otorhinolaryngology, Head and Neck Diseases
The purpose of this study was to evaluate the impact of facial skin reconstruction training videos for head and neck and maxillofacial surgery residents.
This randomized trial, conducted in France, involved residents in head and neck and maxillofacial surgery. A website was created containing facial skin reconstruction training videos. Selected residents performed facial skin flap dissections in the Paris School of Surgery. They were randomized into two groups, one receiving a standard course before the dissection, and the other a standard course plus a video of the flap (“no-video” and “video” groups). Each resident performed 4 facial flaps and was graded (blindly) during dissection. The main study endpoint was intergroup difference in grading score (out of 15). The article was written up following the SQUIRE-EDU (Standards for QUality Improvement Reporting Excellence in EDUcation) criteria.
Eighteen residents were included. For the main endpoint, scores were significantly higher in the “video” than the “no-video” group (6 [IQR, 4: 9] vs. 10 [9: 12]; P < 0.001). In addition, as secondary endpoint, “no-video” group residents requested more assistance (3 [2: 4] vs. 1 [1: 2] P < 0.001). Power was lacking for any subgroup analysis according to year of residency or to the 4 flaps.
Videos improved surgical residents’ performance during dissections. However, these results would be difficult to transpose to real clinical conditions. They need validating in a larger study evaluating performance in real-life procedures.
Developing an educational video on lung lobectomy for the general surgery resident
2015, Journal of Surgical Research
The educational resources available to general surgery residents preparing for complex thoracic surgeries vary greatly in content and target audience. We hypothesized that the preparatory resources could be improved in both efficiency of use and targeting.
A formal needs analysis was performed to determine residents' knowledge gaps and desired format and/or content of an educational tool while preparing for their first lung resections. The results of the needs assessment then guided the creation of a 20-min video tool. The video was evaluated by a focus group of experts for appropriateness to the target audience, ease of use, and relevance.
The needs assessment illustrated that residents feel there is a paucity of appropriate resources available to them while preparing for the lung resection procedure; 82% of respondents felt that easy-to-use and concise resources on the lobectomy procedure were either “not at all” or “somewhat” accessible. Residents reported that video was their preferred format for a learning tool overall and identified a broad spectrum of most challenging procedural aspects. These results were used to guide the creation of a 20-min video tool. A focus group validated the efficacy and appropriateness of the video.
Targeted and efficient tools for residents preparing for complex subspecialty procedures are needed and valued. These results clearly encourage further work in the creation of focused educational tools for surgical residents, especially in the format of short video overviews.
Trimming the fat: Optimizing overall educational value by defining factors associated with overall educational value and service-to-education ratio
2012, Journal of Surgical Education
The Accreditation Council for Graduate Medical Education work rules have forced programs to critically appraise the overall educational value (OEV) of rotations. Successful rotations must satisfy Residency Review Committee mandates and optimize the service-to-education ratio (SER). This study was designed to examine the relationship between the OEV and SER and identify rotation characteristics (RC) associated with both.
The Division of Surgery Education at the Hospital of the University of Pennsylvania administered a survey in FY2011 to all residents detailing resident perceptions regarding OEV, SER, and other RC. Responses were linked to additional rotation data. The relationship between OEV and SER was examined before and after controlling for significant RC identified in univariate analyses. Subgroup analyses by junior (CY1-2) and senior (CY3-5) resident status were performed.
The survey was sent to 85 residents participating in 48 general surgery rotations, with an overall response rate of 87%. OEV was inversely proportional to SER. All RC were significant predictors of OEV in univariate models except rotation length, patient care participation and the presence of fellows. SER alone was a significant predictor of OEV (coefficient = −1.24, p < 0.001) and explained 68% of the variation in OEV. After including other RC, SER remained a significant predictor (coefficient = −1.08, p < 0.001) and the model explained 85% of the variation in OEV. In subgroup analysis, SER remained a significant predictor of OEV for junior residents (coefficient = −1.27, p = < 0.001), but not for senior residents (coefficient = −0.46, p = 0.15).
The SER is inversely correlated with the OEV of general surgery rotations for the aggregate group of surgical residents, but this relationship appears to be attenuated by other factors in the senior resident group. Identification of the factors that affect junior surgical residents may provide the ability to improve the SER for junior residents and allow for significant improvements in perceived OEV for the resident body as a whole.
Operative volume in the new era: A comparison of resident operative volume before and after implementation of 80-hour work week restrictions
2010, Journal of Surgical Education
To determine the effect of the 80-hour work week restrictions on general surgery resident operative volume in a large, community-based, university-affiliated, general surgery residency program.
We performed a retrospective review of Accreditation Council for Graduate Medical Education (ACGME) operative logs of general surgery residents graduating from a single residency. The control group consisted of the residents graduating in the 3 years prior to the work-hour restriction implementation (2001, 2002, and 2003). Our comparison group consisted of those residents graduating in the first 2 classes whose entire residency was conducted after the implementation of the 80-hour work week (2008 and 2009). Comparisons were made between the control and the comparison groups in the 19 ACGME defined categories, total number of major cases, total number of chief cases, and total number of teaching assist cases.
Operative volumes in 13 categories (skin/soft tissue/breast, alimentary tract, abdominal, liver, pancreas, vascular, endocrine, pediatrics, endoscopy, laparoscopic-complex, total chief cases, total major cases, and teaching cases) were not significantly affected by the implementation of the 80-hour work week. One of the 19 categories (laparoscopic-basic) showed a significant increase in operative volume (p < 0.0001). In 4 of the 19 categories (head/neck, operative-trauma, thoracic, and plastics), operative volume was significantly decreased in the post-80-hour work week era (p < 0.05). Nonoperative trauma could not be assessed, as the category did not exist before the work-hour restrictions.
Resident operative volume at our institution's general surgery residency program largely has been unaffected by implementation of the 80-hour work week. Residencies in general surgery can be structured in a manner to allow for compliance with duty-hour regulations while maintaining the required operative volume outlined by the ACGME defined categories.
Impact of the 80-hour workweek on surgical case exposure within a General Surgery residency program
2010, Journal of Surgical Education
Citation Excerpt :
Chung et al16 reported that the implementation of duty hour restrictions resulted in reduced continuity of care, number of consultations seen, and conference attendance, as well as a reduction in the number of operations per week. Jarman and colleagues17 calculated that the residents would miss out on an average of 202 cases over 4 years as a result of duty hour restrictions. A recent survey was administered to surgery program directors about the impact of the current ACGME duty hours standards and recommendations on resident education.
The objective of this statistical analysis was to test the hypothesis that implementation of the 80-hour workweek restrictions for General Surgery residents at Riverside Methodist Hospital after July 2003 decreased their operative experience relative to surgical residents trained at Riverside before these changes.
Data were collected from the Accreditation Council for Graduate Medical Education national database and from Riverside Methodist Hospital's General Surgery Residency records for a sampling of academic years before and after the duty-hour changes in surgical education (July 1, 2003). Current procedural terminology (CPT) surgical procedure codes logged by postgraduate year (PGY) 5 General Surgery residents 15 years before and 5 years after implementation of the 80-hour workweek were compared. The outcome variables “total major cases” and “Chief cases” were compared between 2 study groups defined by the time intervals exclusively before July 2003 (“pre”) and inclusively after July 2003 (“post”). Hospital general surgical case volume for the study intervals was also tallied. Statistical analyses included 1- and 2-sided t-tests, nonparametric tests, and t-tests on a 3-parameter logarithmic transformation of the data.
Despite an upward trend in total general surgery cases (slope = 25/year, p = 0.005), there was a statistically significant decrease in the operative experience for categorical surgical residents following the 80-hour workweek restrictions. The mean (SD) number of major cases performed by “pre”-restriction residents during their training significantly exceeded that of their “post” cohorts (1395 [326] vs 953 [134], p < 0.001). The training for PGY 5 residents was similarly influenced (345 [81] vs 237 [55], p < .0001).
Despite an increase in the total number of major operative cases available, the volume of cases performed by residents has decreased after implementation of the Accreditation Council for Graduate Medical Education (ACGME) work-hour restrictions. Our data suggest that the impact of the 80-hour workweek has had a detrimental effect on the conventional resident training experience.

View all citing articles on Scopus

View full text

2004 APDS spring meeting: Part 2The 80-hour work week: Will we have less-experienced graduating surgeons?

Objective

Design

Setting

Participants

Results

Conclusions

Introduction

Section snippets

Materials and methods

Results

Discussion

Acknowledgments

J Am Coll Surg

J Am Coll Surg

2004 APDS spring meeting: Part 2
The 80-hour work week: Will we have less-experienced graduating surgeons?