The Early Effects of Code 405 Work Rules on Attitudes of Orthopaedic Residents and Attending Surgeons

Zuckerman, Joseph D. MD; Kubiak, Eric N. MD; Immerman, Igor BS; DiCesare, Paul MD

Journal of Bone & Joint Surgery - American Volume:
doi: 10.2106/JBJS.D.02801
The Orthopaedic Forum
Abstract

Background: The impact of strict enforcement of Section 405 of the New York State Public Health Code to restrict resident work to eighty hours per week and the adoption of a similar policy by the Accreditation Council on Graduate Medical Education in 2002 for orthopaedic residency training have not been evaluated. Adoption of these rules has created accreditation as well as staffing problems and has generated controversy in the surgical training community. The purposes of this study were (1) to evaluate the attitudes of orthopaedic residents and attending surgeons toward the Code 405 work-hour regulations and the effect of those regulations on the perceived quality of residency training, quality of life, and patient care and (2) to quantify the effect of the work-hour restrictions on the actual number of hours worked.

Methods: We administered a thirty-four-question Likert-style questionnaire to forty-eight orthopaedic surgery residents (postgraduate years [PGY]-2 through 5) and a similar twenty-nine-question Likert-style questionnaire to thirty-nine orthopaedic attending surgeons. All questionnaires were collected anonymously and analyzed. Additionally, resident work hours before and after strict enforcement of the Code 405 regulations were obtained from resident time sheets.

Results: The average weekly work hours decreased from 89.25 to 74.25 hours for PGY-2 residents and from 86.5 to 73.25 hours for PGY-3 residents, and they increased from 61.5 to 68.5 hours for PGY-4 residents. Residents at all levels felt that they had increased time available for reading. There was general agreement between attending and resident surgeons that their operating experience had been negatively impacted. Senior residents thought that their education had been negatively affected, while junior residents thought that their operating experience in general had been negatively affected. Senior residents and attending surgeons felt that continuity of care had been negatively impacted. All agreed that quality of life for the residents had improved and that residents were more rested.

Conclusions: On the basis of the survey data, the implementation of the new work-hour restrictions was found to result in a decrease in the number of hours worked per week for PGY-2 and PGY-3 residents and in an increase in work hours for PGY-4 residents. This could explain the definite difference between the attitudes expressed by the senior residents and those of the junior residents. Senior residents felt that their education was negatively impacted by the work rules, while junior residents expressed a more neutral view. However, senior residents did not believe that their operative experience was as negatively impacted as did junior residents. Although junior and senior residents and attending surgeons agreed that resident quality of life had improved, we were not able to determine whether this offset the perceived negative impact on education, continuity of care, and operative experience.

Author Information

1 Department of Orthopaedic Surgery, New York University-Hospital for Joint Diseases, 301 East 17th Street, 14th Floor, New York, NY 10003. E-mail address for J.D. Zuckerman: joseph.zuckerman@med.nyu.edu

Article Outline

After the well-publicized death of eighteen-year-old Libby Zion while under the care of a medical intern and a resident, both of whom had been working for eighteen continuous hours, the New York State Department of Health convened the Bell Commission1,2. This commission determined that lack of supervision and residents' fatigue contribute to medical errors that compromise patient care. In response, the Bell Commission authored a report that led to the enactment of Section 405 of the New York Public Health Code3,4. It provided for the restriction of the hours worked by residents to eighty hours per week averaged over a four-week period; residents were allowed to work a maximum of twenty-four hours continuously with a three-hour transition period, all work shifts had to be separated by at least eight hours, and each resident had to have at least one twenty-four-hour period of “non-working” time scheduled per week. Since the Bell Commission released these recommendations in 1989, regulation of resident work hours has been the focus of the New York State Department of Health and, more recently, the federal government5,6 and the Accreditation Council for Graduate Medical Education (ACGME). The ACGME recently established resident work-hour guidelines (www.acgme.com), which are quite similar to those included in the Code 405 regulations.

Although intuitively it makes sense that fatigued residents make more mistakes, studies investigating the effects of sleep deprivation and shortened work shifts on resident work performance and the incidence of patient errors have been inconclusive and contradictory7-10. The implementation of the new work rules has created controversy in the surgical community as well as staffing problems in academic and community hospitals, which rely on resident activity, and it has led to accreditation problems at prominent academic institutions11,12.

The goal of orthopaedic residency training is to educate young physicians so that they acquire the fund of knowledge, clinical judgment, operative skills, communication skills, systems management, and professionalism to practice orthopaedic surgery. The long-term effects of strict enforcement of the Code 405 regulations on physician attitudes (in particular those of orthopaedic surgery residents), patient care, and health care costs are unknown. It is unclear whether the new regulations will result in an improvement in resident education and resident quality of life, or whether the decrease in work hours will detract from the crucial in-hospital experiences previously gained by residents who worked longer hours. The adoption of these regulations nationally by the ACGME makes it imperative that we understand the effects of the enforcement of resident work-hour rules.

We conducted a survey to assess the early effects of Code 405 regulations on orthopaedic resident education and patient care within a large orthopaedic residency training program. Our residency training program is uniquely suited to conduct such a survey because of the fact that it is one of the largest in the country. Since February 2002, we have been in strict compliance with the Code 405 regulations and resident work hours, and the call schedules for all of the residents have been changed in order to ensure strict adherence to all regulations.

The goal of this assessment was to evaluate the perceptions of the residents and faculty with regard to resident quality of life, the quality of patient care, and resident education and operative experience before and after the enactment of Code 405 regulations.

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Materials and Methods

We used an anonymous survey to evaluate the opinions of the residents and attending surgeons regarding resident education and patient care. The residents received a thirty-four-question survey that addressed the effect of the new work rules on resident education in general, their own education, resident quality of life, and patient care. The attending surgeons received a twenty-nine-question survey based on the resident survey but with the deletion of the ten questions related to the resident assessment of their own education and the addition of five questions specifically related to the attending surgeon's assessment of resident knowledge and preparation. All questions in the survey were attitudinal and were formatted in 5-point Likert scales, which provided the opportunity to agree or disagree with a specific statement on a graduated scale. Both surveys are included in the Appendix.

After obtaining approval from the institutional review board, we administered the survey to forty-eight orthopaedic surgery residents in post-graduate years (PGY) 2 through 5 and to thirty-nine orthopaedic attending surgeons who were members of the teaching faculty. All were informed of the purpose of this study and were assured that their responses would be completely anonymous other than identification as either an attending surgeon or as a resident with the post-graduate year indicated. Participation in the survey was voluntary. Informed consent was obtained from all participants. The responses to a specific statement in the questionnaire were graded on a 5-point scale with: 1 indicating strong disagreement; 2, moderate disagreement; 3, no opinion; 4, moderate agreement; and 5, strong agreement. All questionnaires were collected in a slitted box to maintain anonymity.

Resident work hours were calculated from weekly resident time sheets collected before and after enforcement of resident work-hour restrictions. In addition, the time sheets were compared with call schedules to confirm that in-house on-call hours were properly documented and that residents fulfilled the other requirements of the work rules, including one full day off every week and no more than a three-hour transition time after working continuously for twenty-four hours.

The mean value for each question on the 5-point Likert scale was used to compare the responses of the junior residents and the senior residents as well as the responses of the resident group and the attending surgeon group. The statistical analyses were performed with a nonparametric t test (Mann-Whitney test), nonparametric one-way analysis of variance (Kruskal-Wallis test), and the Dunn post test to compare all pairs of columns.

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Results

Resident work hours before and after the enforcement of work-hour restrictions are summarized in Table I. Data for junior and senior residents at two institutions, including the residents with in-house and out-of-house on-call responsibilities, were calculated. For PGY-2 residents, the average weekly work hours decreased from 89.25 to 74.25 hours. We estimate that this decrease was primarily due to the time lost from the operating-room experience when the residents would usually be involved in operations on patients who were admitted when the residents had been on call the night before. For PGY-3 residents, the work hours decreased a comparable amount from 86.5 to 73.25 hours. Also, by our estimate, the decrease was due to less operating-room time. For the PGY-4 residents, the amount of work hours increased at both institutions. At the private tertiary-care institution, the work hours increased from 61.5 to 68.5 hours. For the city hospital rotation, the work hours increased from 63.5 to 73.0 hours. The increase in work hours for PGY-4 residents reflected a larger average work day performing the tasks that previously would have most likely been performed by PGY-2 and PGY-3 residents. Work hours before and after enforcement of the work rules were comparable for PGY-5 residents.

The assessment of the impact of the work rules on resident education in general, including operating-room experience and decision-making skills, was generally similar between residents and attending surgeons, with some differences noted between junior and senior residents (Table II). Residents at all levels believed that the time available for reading had increased, although junior residents felt this way more strongly than did the senior residents. There was general agreement among residents and attending surgeons that operating-room time and experience had been negatively impacted. Senior residents did not think that resident education had improved, that they made better clinical decisions, or that the work rules were beneficial to training. Their assessment was quite similar to that of the attending surgeons, whereas the junior residents (PGY-2 and PGY-3) had a more neutral view of the impact on resident education. When the junior and senior residents were specifically asked to assess the impact of the work rules on their education, the responses were somewhat different. The junior residents believed that they had much more time for reading, whereas the senior residents felt that they did not. The senior residents thought that their education, ability to make clinical decisions, and overall training were somewhat negatively impacted by the work rules, whereas the junior residents were more neutral on these areas. The junior residents thought that their operating-room time and experience were more negatively impacted than did the senior residents (Table III).

Junior residents and attending surgeons believed that quality of life for the residents had improved, whereas senior residents felt less strongly about this. All believed that the residents were more rested, but they all were more neutral concerning the impact of the work-rule changes on whether more time was spent with their families (Table IV).

The perceived impact of the work rules on patient care was also assessed (Table V). Senior residents and attending surgeons believed that continuity of patient care was negatively impacted. Junior residents and attending surgeons thought that having the next day off did not positively impact patient care, whereas senior residents believed that it did. Senior residents felt strongly that the work rules led to a deterioration in the resident work ethic; junior residents disagreed, and attending surgeons were more neutral on the issue. Senior residents also believed that the quality of patient care had declined; junior residents and attending surgeons thought that it had not. When asked whether the quality of patient care had improved, junior residents felt that it had and senior residents did not; attending surgeons were more neutral on this question. Senior residents believed that the frequency of patient-care errors had decreased somewhat; junior residents disagreed, as did attending surgeons. Junior residents thought that the Code 405 work rules were somewhat beneficial to patient care, whereas senior residents and attending surgeons disagreed somewhat with this statement.

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Discussion

This survey was performed to assess the perceived impact of the new resident work rules on resident education and patient care in a large university-based orthopaedic residency program in an urban setting. It was performed one year after our program initiated strict compliance with the work rules. The timing of the questionnaire was chosen to maximize the number of residents who experienced the environment both before and after enforcement of the work rules. By minimizing the number of residents who had graduated from the program, we believed that we were able to obtain a real-time assessment by all residents involved.

In general, the residents were concerned about the negative impact on their operating-room experience. This could be a very valid concern on the basis of our analysis that each junior resident would lose between twelve and twenty-four hours in the operating room per week by going home the day after in-house call. The number of cases this translates into cannot be determined at this time—nor can its overall significance. It is very possible that this operating-room experience will be subsumed by other junior residents or will become a senior resident experience, and the overall impact on training may be minimized. This can only be determined by longer-term analysis of operative caseloads reported by each resident at the time of completion of the residency program. Since operative cases are now tracked by the ACGME, an overall decline in surgical case volume should be easy to identify in longitudinal studies. However, the impact of less operating-room experience as a junior resident may translate into a longer learning curve during the residency program. It is possible that, even if overall case volumes do not decline, the quality of the experience may be changed to the detriment of overall training. This will be an important question to consider as more data become available.

The junior residents expressed different opinions about the impact of the work rules on resident education in general compared with their own educational experience. Specifically, junior residents believed that their own education and their clinical decision-making were relatively unaffected. Junior residents also felt that the impact of the work rules on residency training in general for these two areas was minimal. The same view was evident with respect to whether the work rules had been beneficial to training. It is also interesting that junior and senior residents believed that the work rules had a positive impact on quality of life. The fact that the attending surgeons also agreed that the residents had improvement in the quality of life, were more rested, and spent more time with their families is not surprising as, in general, the attending surgeons represent the long-established view that the long hours and sleep deprivation are a rite of passage of residency training.

The issue of whether the work rules have had a negative impact on the quality of patient care and the frequency of patient-care errors is difficult to assess accurately. In our program, senior residents believed that patient care was adversely impacted; junior residents felt that it was not. Other studies have attempted to answer this question, and the results have generally been inconclusive and contradictory. Since the inception of Code 405, Barden et al. showed that the residents' quality of life and education had improved, as evidenced by improved in-training examination scores13. Whang et al. conducted a survey of surgical residents in New York State in 2003. They surveyed thirty-one surgical training programs (1037 residents), both in academic medical centers and community hospitals14. Of the 319 respondents, 75% worked at academic medical centers and 25% worked in community hospitals. The majority of residents reported spending fewer hours in the hospital, feeling more rested, and experiencing general improvements in the quality of work life and social life. Similar to our study, when the responses of senior residents were separated from those of junior residents, senior residents reported generally increased work hours, increased work intensity, and decreased quality of life. Hassett et al., in a survey of surgical residents at the State University of New York in Buffalo, reported that the overall quality of life of the residents was improved, there was no substantial change in procedures performed, and 90% of residents were passing their qualifying examinations15.

In the present study, 33% of the residents believed that the Code 405 changes had negatively affected their training and >50% thought that patient care had been negatively affected. These findings were consistent with those of Barden et al., who reported that residents and attending surgeons thought that patient care had worsened since the implementation of the new work rules13.

The implementation of Code 405 may, in fact, increase the number of resident errors by increasing the number of shift changes and patient cross-coverage. The American College of Surgeons expressed concern over this issue in 1988, stating that “lack of familiarity with a patient, not fatigue, is the major cause of errors of judgment.”16 A study by Laine et al. showed that after the enactment of Code 405, the number of in-hospital complications and delays in diagnostic testing increased because of the lack of continuity of care17. Petersen et al. similarly showed that preventable complications in patient care were two times higher in cross-covered patients than in patients who were cared for by their primary team of residents18.

Most of the studies of the effect of work rules on resident work attitudes, education, and patient care are limited by the same factors that limit our survey. In considering the results of this survey, it is important to recognize its inherent limitations, specifically the information that it can provide and the information it cannot. The survey was designed to document the opinions of residents and faculty in a large urban residency program. It was not designed to provide objective documentation of the changes that occurred before and after enforcement of the work rules. Information concerning patient-care errors, change in in-training examination scores, and the impact of any change or shift in operative volume during training would certainly be appropriate areas to study when evaluating the impact of these work rules. Assessment of these areas requires a longitudinal study, which was not the purpose of this survey and could not be completed in the time frame that we used; however, the information we obtained is useful and certainly provides a starting point for future studies.

There has been concern expressed within the medical community that the work rules have given rise to a “shift mentality,” resulting in a different attitude toward patient care and ultimately a compromise of professionalism. Those who are concerned focus on the loss of continuity of patient care and, specifically, the responsibility and commitment to care for a patient until the care can be safely turned over to “the team” as opposed to when the twenty-four-hour limit has been reached5. In reality, physicians frequently transfer the care of patients to colleagues when call schedules change or other patient-care responsibilities are scheduled. It is impossible to follow one's patients at all times; care must be transferred if any physician is to have the opportunity to rest and recover from long periods of continuous patient-care activity. Attending surgeons are used to this occurring and consider it an important part of their practices. Such transitions occur much less frequently and after longer intervals for residents. The work rules in many ways have blended the differences between residents and attending surgeons. Whether the work rules have a negative or a positive impact on how future residents practice orthopaedic surgery after their training and on patient care remains to be determined. At present, there are more questions than answers concerning the resident work rules. With each year, as our experience with the work rules increases, the impact will be better understood. It is our responsibility to answer these important questions for the benefit of residency training and particularly for the patients we treat.

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Appendix

The survey questionnaires that were used for the attending surgeons and residents are available with the electronic versions of this article, on our web site at jbjs.org (go to the article citation and click on “Supplementary Material”) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

NOTE: The authors thank Jim Madden for his expert assistance in the preparation of the manuscript.

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at the Department of Orthopaedic Surgery, New York University-Hospital for Joint Diseases, New York, NY

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