Impact of Resident Duty-Hour Reform on Faculty Clinical Productivity

doi:10.1016/j.cursur.2005.08.013

Current Surgery

Volume 63, Issue 1, January 2006, Pages 74-79

https://doi.org/10.1016/j.cursur.2005.08.013 Get rights and content

Objective

Prior data have shown that resident duty-hour reform has not affected faculty work hours; yet the preservation of faculty hours may have been at the expense of productivity. We sought to examine change in clinical productivity.

Design

Anonymous survey and analysis of faculty relative value units (RVU) database

Setting

A single, large academic medical center.

Participants

All clinical faculty in the Department of Surgery.

Methods

An anonymous survey was distributed to surgical faculty 18 months after reform and compared with surveys taken before and after reform. Opinions regarding productivity and working hours were solicited. P values were determined by chi-square or Student t-tests. Relative value unit data, reflecting clinical productivity, were compared before and after reform. Regression was performed with dependent variable “lnRVU” and independent variables “calendar month,” “pre/post” July 2003, and “surgeon.” The coefficient on “pre/post” reflected average change in RVUs.

Results

A total of 49 of 73 surveys were returned (67% response). Faculty reported an average of 68.0 ± 7.0 weekly work hours (p = NS compared with previous survey). In the current survey, 35% felt their overall productivity had fallen due to reform. Among these, 83% felt academic productivity had suffered, 11% were unsure, and 1 person (6%) believed academic productivity was preserved. The majority (82%) reported preserved clinical productivity, 6% reported a decrease, and 12% were unsure. Overall, 60% reported doing work previously done by residents. When RVU data were examined, the coefficient on change pre- and post-reform indicated a 5.7% increase in productivity (p = 0.005). However, this effect was driven by 5 surgeons with a greater than 75% increase in productivity, all young faculty, early in practice. Excluding these, there was no significant change (0.6% increase, p = 0.77).

Conclusions

Faculty have preserved work hours and clinical productivity, despite a tendency to take on work previously done by residents. This suggests that academic activities may have suffered.

Introduction

The implementation of the Accreditation Council for Graduate Medical Education’s (ACGME) mandated reduction in resident duty hours is now complete. Programs have dealt with these mandates in a variety of ways, and for some, the adaptation continues to evolve. Although many other groups have examined these changes with regard to resident impact, we have been interested in studying the impact of duty-hour reform on faculty.1, 2 Our previous work has shown that faculty work hours in our academic medical center did not significantly change after institution of the resident 80-hour workweek.1, 2

Before duty-hour reform, several authors predicted negative impacts on faculty. Weinstein³ predicted: “Attending physicians can be asked to take a more direct role in patient care. However, a substantial, systematic expansion of the clinical responsibilities of faculty members will inevitably curtail academic productivity.” Croasdale⁴ reported in early 2003 (before the July 2003 institution of duty-hour reform) that the impact would be more profound on younger faculty: “junior faculty … are fearing for their lives…if you are junior faculty with the pressure to publish or perish, that threatens your academic livelihood.” Fry⁵ reported, “…nearly 18 months into full compliance with the resident 80 hour work week…the dissatisfaction of the residents has been fully transferred to the dissatisfaction of the attending staff.” Despite this pessimism, we have been unable to demonstrate that the numbers of hours worked on a weekly basis by faculty has significantly changed as a result of duty-hour reform.²

Although our faculty hours seem to be preserved, how the faculty spent those hours may have significantly changed. The aim of this study was to examine faculty productivity, through surveying their duty hours this year, allowing comparison to work-hour data from prior survey periods spanning the time before and after resident duty-hour reform. We also sought faculty opinions on resident education, faculty workload, allocation of time, and productivity. We specifically hoped to quantify the clinical productivity of our faculty, using total relative value units (RVUs) as an indicator, comparing RVU data before and after resident duty-hour reform.

Section snippets

Survey

After obtaining Institutional Review Board (IRB) approval from the Washington University School of Medicine, a cross-sectional survey of surgical faculty from the Department of Surgery (including cardiothoracic, endocrine/oncology, hepatobiliary, vascular, colorectal, transplant, pediatrics, trauma/critical care, urology, and plastic surgery) was undertaken. Unlike our previous 2 studies, this survey did not include surgeons from otolaryngology, orthopedics, or neurosurgery, as the RVU database

Study Population

A total of 73 surveys were sent; 49 were returned, for a response rate of 67% (response rate for women: 78%; for men: 65%). Forty-two respondents were men (85%), and 7 respondents were women (15%). The sections of colorectal, vascular, cardiothoracic, hepatobiliary, and urology each had 5 respondents (10.2% of respondents); transplant 3 (6.1%), endocrine/oncology and trauma/critical care 6 (12.2%), plastics 7 (14.3%), and pediatric surgery 2 (4%). The mean number of years in practice was 11 ±

Discussion

Although the debate on the relative merits of resident duty-hour reform on residents may be abating, the impact of these reforms on faculty will likely continue to be the subject of focus and debate. We have shown that the weekly work hours of faculty are not significantly affected by limits on resident duty hours and that, at least during the period examined in our current survey, clinical productivity has not been adversely affected.

The responsibilities of academic surgeons are numerous, but

Acknowledgments

Assistance with RVU data was provided by Vivian Boyd, MBA, Department of Surgery.

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Citation Excerpt :
It is a commonly held belief that implementation of the 80 hour work week for residents has led to a population of young physicians with attitudes and lifestyle needs in contrast to the work hours and productivity of older surgeons. Certainly, there is evidence that resident work hour restrictions have directly decreased the productivity of academic faculty surgeons.27 And, although historically an individual surgeon's productivity has increased to a peak between ages 50 and 54, current thought is that today's young surgeons will not follow that pattern of increasing productivity with age, but instead will maintain a constant level of productivity throughout their careers.1,4,28
To estimate the size of the future workforce in vascular surgery (VS) and the added cost associated with addressing the projected shortage in the United States.
The net supply (number of Vascular Surgeons [VSN] currently practicing, new graduates entering the workforce, and those retiring) for each decade was calculated. The projected population for each decade was determined by U.S. Census Bureau figures. Some assumptions of this model included: (1) In 2008, the population was 300,000,000; (2) There were 2783 board certified VSN in 2008; (3) VSN will practice 30 years from board certification to retirement; (4) There will be 105 board certifications and 93 retirements per year; (5) Vascular operations will remain at 284 per 100,000 population; (6) Salaries of trainees will be $50,000 with benefits of 30% and $15,000 of additional direct medical education costs.
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A conservative estimate by both population and workload analysis, disregarding aging of the population, lifestyle choices of future VSN, and increasing demand for services, indicates a shortage of VSN in the future. Unless the Balanced Budget Act of 1997 is revised by Congress, the cost to train the additional VS workforce remains a significant barrier.
Resident duty hours in surgery for ensuring patient safety, providing optimum resident education and training, and promoting resident well-being: A response from the American College of Surgeons to the Report of the Institute of Medicine, "Resident Duty Hours: Enhancing Sleep, Supervision, and Safety"
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Klingensmith et al. surveyed general surgery faculty members after the implementation of the 2003 duty hour restrictions. Of those surveyed, 83% felt academic productivity had suffered following resident work hour restrictions, 60% of the respondents believed that this was in part owing to the need for general surgery attendings to perform clinical tasks that had previously been done by residents.7 Our primary objective in this study was to examine whether resident academic productivity, has increased following implementation of the 2011 ACGME duty hour restrictions.
In 2003 and again in 2011, the Accreditation Council for Graduate Medical Education (ACGME) mandated increasingly stringent resident duty hour restrictions. With less time required at the hospital, residents theoretically have more time for other academic activities, such as research. Our study seeks to examine whether the number of research publications by orthopaedic residents increased following implementation of the 2011 ACGME duty hour restrictions.
Pubmed was queried using publicly available alumni lists from programs across the United States. The years 2008 to 2011 were included to assess pre-2011 productivity. The years 2012 to 2015 were included in the post 2011 group. Paired t tests were used to assess differences between groups. Statistical significance was set to p < 0.05 a priori.
A total of 10 orthopedic surgery residency programs across the United States.
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When corrected for number of residents per year, there were 0.290 publications per resident/year from 2008 to 2011 increasing to 0.528 publications per resident/year from 2012 to 2015 following implementation of the 2011 work hour restrictions (p = 0.033). When corrected for number of residents per year, there remained no difference in publications per resident from 2008 to 2011 (p = 0.81) or from 2012 to 2015 (p = 0.10) between NIH and non-NIH funded programs.
There has been little data to support the theory that resident work hour restrictions have improved education or patient care in any meaningful way. In our study, there was a statistically significant increase in publications after 2011; however, the number of publications between NIH funded and non-NIH funded programs did not differ. Our study is the first to demonstrate that with increasing duty hour restrictions, orthopaedic surgery residents may be using more of their free time to conduct research.
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: B.L.H. is supported by the Center for Health Policy at Washington University, with gratitude to Dr. William Peck, Director.

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2005 APDS Spring meetingImpact of Resident Duty-Hour Reform on Faculty Clinical Productivity

Objective

Design

Setting

Participants

Methods

Results

Conclusions

Introduction

Section snippets

Survey

Study Population

Discussion

Acknowledgments

JACS

Curr Surg

Am J Surg

Surgery

Duty hours for resident physicians-tough choices for teaching hospitals

N Engl J Med

ACGME gives final nod to 80-hour workweek

In discussion accompanying manuscript “Survey of residents and faculty regarding work hour limitations in surgical training programs”

Arch Surg

2005 APDS Spring meeting
Impact of Resident Duty-Hour Reform on Faculty Clinical Productivity