On July 1, 2003, the Accreditation Council on Graduate Medical Education (ACGME) implemented the eighty-hour workweek rules, which set limits on the number of hours that residents in the United States are allowed to work1. Specifically, the ACGME rules mandate that residents are not allowed to be on duty for more than eighty hours per week averaged over a four-week period, and they may not take in-house call more frequently than every third night. Additionally, the regulations state that residents must have ten hours off between shifts and must have one twenty-four-hour period per week free from clinical duties. Finally, the maximum duration of a work shift is twenty-four hours, with an optional extension of six extra hours for other educational activities.
This new policy was the culmination of years of media attention and academic debate regarding the effects of excessive work hours on the performance and well-being of house staff, most specifically the risks that sleep-deprived residents posed to the patients for whom they were caring. The 1984 case of Libby Zion and the subsequent findings and recommendations of the Bell Commission did much to inspire the eighty-hour duty-week movement in New York and then nationally2. In this unfortunate circumstance, the patient died while under the care of a fatigued member of the house staff, but the case and controversy that followed focused more on resident supervision than on the issue of fatigue.
In addition to the national exposure received by the Libby Zion story, studies pertaining to house-staff fatigue began to appear nationally3-5. A 1991 article in the Journal of the American Medical Association reported that 41% of the 114 residents surveyed felt that they had made their most serious medical mistakes secondary to fatigue, and that a third of these errors resulted in the demise of a patient6.
Following the implementation of the ACGME duty rules, many residency training programs went through a period of adjustment, altering call schedules and hiring additional ancillary staff to fill the service gap created by the decreased availability of residents. Despite these changes, few medical and surgical specialties have conducted widespread surveys of their own programs to determine the effects of the new rules on residents within that particular specialty. In the current study, we report the results of a large, nationwide survey of orthopaedic residents to understand the attitudes and compliance of these house-staff members toward the new rules. Strategies used by training programs in response to these new mandates were also identified.
Materials and Methods
The Academic Advocacy Committee of the American Academy of Orthopaedic Surgeons (AAOS) created a survey on resident duty-hour issues (see Appendix). Committee membership included junior and senior orthopaedic residents, attending physicians from academic orthopaedic surgery training programs, and staff members of the AAOS. The survey was created with several objectives in mind: (1) to determine the compliance of house staff with the new rules, (2) to identify methods by which training programs have measured the number of hours that residents were on duty, (3) to measure the attitudes of residents toward the new duty rules, (4) to understand how programs have dealt with the decreased availability of residents as a result of the rules, (5) to assess the perceived impact of the rules on resident quality of life, well-being, and educational experience, and (6) to record the perceived effects of the work rules by residents on the quality and continuity of patient care. When it was possible, the responses of junior and senior residents were compared. The surveys also contained open-ended sections that allowed respondents to enter additional comments regarding the new regulations.
In order to compare the responses of house staff at different stages of training, residents were categorized as junior residents if they were at the postgraduate year (PGY)-1 through PGY-3 level and as senior residents if they were at the PGY-4 through PGY-6 level.
Data analyzed in the survey were collected in two rounds. On July 22 and 23, 2004, the survey was distributed to 1955 orthopaedic residents from all postgraduate-year levels for whom a mail or fax address was available. Data collection from this group was halted on August 13, 2004, and the data were compiled. On November 1, 2004, an additional 2252 residents for whom an e-mail address was available and who had not responded to the initial round of data collection were contacted by e-mail with a link to an Internet site for completion of the survey. On December 1, 2004, data collection for this second round was discontinued. The responses from the two data collection rounds were combined and electronically tabulated. At all times in the process, the survey results were maintained with strict confidentiality. Survey data were analyzed for validity and accuracy by the Department of Research and Scientific Affairs of the AAOS.
When necessary, statistical analysis was performed with use of a paired Student t test and a t test for probabilities. Significance was set at α = 0.05. All statistics were performed with use of Stata software (Stata, College Station, Texas).
The survey was distributed to a total of 4207 orthopaedic trainees. The aggregated response rate of both rounds of survey distribution was 13.2% (554 respondents). The responses of these 554 residents were analyzed. Of note, fifty-nine responses were from orthopaedic fellows or residents of unknown postgraduate-year status. This left 495 residents whose postgraduate-year status was known. When analyzing the responses to survey questions that involved stratification by postgraduate-year level, the responses of only those 495 residents whose postgraduate-year level was known were analyzed. However, in all other survey questions that did not involve stratification by postgraduate-year level, the responses of all 554 respondents were analyzed.
Seventy-six percent of the 554 respondents were enrolled in academic residency programs, and 16% were in community hospital-based programs. Five percent of the respondents were enrolled in military-sponsored programs, and 3% failed to indicate the type of program in which they were participating. Of the 495 respondents whose postgraduate-year level was known, 158 (32%) were junior residents, while 337 (68%) were senior residents. Sixty-six percent of the 554 respondents indicated that their residency programs consisted of between ten and twenty-five residents.
Compliance with Duty-Hour Restrictions
Eighty-five percent (469) of the respondents indicated that they consistently worked eighty hours or less, averaged over four weeks, after the implementation of the new rules. Eighty percent responded that they worked between sixty and eighty hours. However, 33% of the respondents reported working greater than eighty hours during at least one single one-week period after July 1, 2003; this occurred more commonly among PGY-3 and more junior residents.
The responses regarding the procedures for reporting hours on duty at the respondents' institutions demonstrated that, overall, 33% of all residents had intentionally underreported their work hours during a week in which they exceeded eighty hours (Fig. 1). Forty-two percent (sixty-six) of the 158 junior residents had intentionally underreported the number of hours on duty at least once, while 29% (ninety-eight) of the 337 senior residents had submitted similar misrepresentations. Only 14% of all 554 respondents indicated that they always reported rule infractions to appropriate authorities, while 32% indicated that they never reported such violations. The reasons why the respondents intentionally misrepresented their duty hours were varied. The reasons cited most often included concerns that their programs would be penalized for violations (28% of the respondents), concern about personal citations (14%), and disagreement with the importance of reporting and complying with the eighty-hour rules (14%).
Data were also collected on the method by which the home institutions of the respondents monitored duty hours. Fifty-eight percent (324) of the residents reported that their home institution utilized some form of a self-reporting system to monitor hours. Under such a system, residents themselves were responsible for calculating and reporting duty hours. Other slightly more rigorous methods used for reporting duty hours included written logs (28% of the residents) and electronic logs (22%). Only 1% of the residents reported the use of more rigorous systems of logging hours, such as electronic swipe cards or outside, external monitoring systems.
The quality of monitoring hours on duty was rated on a 5-point scale (with 1 indicating that the monitoring was extremely poor; 2, poor; 3, average; 4, good; and 5, extremely well done); the average response was 4.2 points. The residents' perception of the accuracy of their parent institution in monitoring hours on duty demonstrated that 77% thought that this reflected a “good” job. Forty-four percent believed that monitoring of duty hours by their institution was done “extremely well,” while <2% thought that their institution was “extremely poor” in this respect. Interestingly, 48% of the 337 senior residents indicated that their institutions monitored hours “extremely well,” while only 37% of the 158 junior residents felt this way (p = 0.017).
Only twenty-three percent of the 554 respondents felt that eighty hours constituted an appropriate number of duty hours per week; 41% thought that a shorter duty schedule was appropriate, while 34% preferred the opportunity to be on duty more than eighty hours per week. More specifically, 37.2% felt that a sixty to seventy-nine-hour workweek was optimal, while 31.5% were of the opinion that an eighty to ninety-nine-hour week was ideal. Twenty-seven percent of the 158 junior residents and 24% of the 337 senior residents felt that eighty hours constituted an optimal work week. Forty percent of the 554 respondents believed that the duty rules resulted in favorable changes in their training programs (Table I). However, 56% of the junior residents felt that the training program had improved after implementation of the duty rules, while only 38% of the senior residents expressed similar sentiments (p = 0.0002). Overall, 48% of all residents thought that they had personally benefited from the duty rules; 74% of the junior residents expressed this opinion compared with only 42% of the senior residents (p = 0.00002). The respondents indicated that, on the average, 70% of duty time was educationally valuable, while 24% of the hours consisted of “scut” work. More detailed analysis of this question according to the year in training revealed little difference in responses. Other attitudes regarding the eighty-hour workweek included the fact that only 24% of the respondents felt that the duty rules had caused deficits in learning and training experiences, and only 16% of the respondents believed that continuity of care had suffered. Ten percent of the respondents felt that the rules required senior residents to increase their workload to compensate for reduced hours by junior residents. Similarly, 10% of the respondents felt that the changes resulted in a “shift-worker” mentality, primarily among the junior residents. Overall, only 13% of the respondents felt that the changes in the duty rules had caused no new problems to the residency training program.
Information concerning changes made by residency programs in their respective duty schedules to comply with the eighty-hour rules was also solicited. Eighty-two percent of the residents reported that their program had made at least one change to their rotation schedules to be in compliance. Fifty-seven percent of the respondents reported that their program allowed residents to assist in the design and implementation of new rotation schedules. The most common strategies included increasing the number of home-call assignments (28% of the respondents), the use of physician assistants or moonlighters (25%), and the use of a night-float system (22%) (Fig. 2). Interestingly, 60% of the respondents indicated that the changes in rotations required for compliance had positive effects on the residency program.
As expected, the orthopaedic service area that had the most difficulty complying with the duty rules was orthopaedic trauma. Eighty-one percent of the residents reported that trauma services at their institutions encountered substantial obstacles to complying with the new rules. The two other service areas that were identified as frequently having compliance issues were adult reconstruction (hip and knee arthroplasty) and spine surgery, with 24% of the residents citing these services.
Regarding quality-of-life issues, 58% of the respondents reported that, after the implementation of the new rules, most of their fellow residents were generally happier with their training experiences and 57% indicated that they were getting more rest. Junior residents were generally more in favor of the duty-hour rules and perceived more positive effects from the new restrictions (Table I). This is evidenced by the fact that 56% of the junior residents in our survey indicated that their training program had improved after implementation of the hour restrictions (compared with 38% of the senior residents), and 74% of the junior residents believed that they had personally benefited from the new rules (compared with 42% of the senior residents). Additionally, with regard to the issue of time for rest, 68% of the junior residents indicated they had more time for rest, while 56% of the senior residents felt they had more time for rest (p = 0.01).
Quality of Patient Care
The opinions of the respondents regarding the effects of the duty-hour restrictions on the quality of patient care delivered were mixed. Overall, 38% of the respondents felt that patient care had decreased in quality in some way after the duty restrictions were implemented, while 51% perceived no such decline. Interestingly, there was no difference in opinion between the junior and senior residents regarding this question of quality of care.
The most commonly cited manifestations of decreases in quality were lapses in continuity of care (35% of the respondents), missed injuries (16%), unnecessarily increased length of hospital stay due to limited staff (10%), and more inpatient complications (8%).
The eighty-hour workweek rules mandated by the ACGME have already had and will continue to have a substantial impact on the structure of residency training programs. Residency programs have had to be innovative in devising strategies to enable compliance with these rules. Training programs in fields such as internal medicine, obstetrics and gynecology, and pediatrics have used approaches to reduce resident work hours for several years prior to the implementation of the ACGME mandates on July 1, 20037,8. Therefore, most current studies in the literature that have examined the effects of the duty-hour rules on residents and on their attitudes have dealt with nonsurgical specialties. The present study represents one of the largest nationwide surveys of residents in a surgical specialty regarding the impact of the new rules. Despite the fact that implementation of the new rules caused substantial infrastructure challenges to orthopaedic residency training, the net result with regard to resident attitudes toward these challenges and reduced work hours has been positive.
First, the data indicate that most residents believe that their training environment has been improved by the implementation of the new duty-hour requirements. Other surgical specialties have reported clinical psychologic distress among their residents that has been attributed to the large number of hours worked9. The perception of an improved work environment by orthopaedic residents in the current study may be a result of decreased psychologic stress concurrent with a decrease in the number of hours worked. Particularly, our data indicate that, among orthopaedic residents, junior residents are more in favor of the duty-hour rules and perceive more positive effects from the new duty-hour restrictions. Chandra, in 2004, surveyed forty-six surgical subspecialty residents and attending physicians and similarly found that senior residents and faculty were “less accepting” of the restrictions in comparison with junior residents10.
Additionally, the results demonstrated that, among orthopaedic residents, there is no agreement on the number of hours that constitute an ideal duty week. Only 23% of the respondents in our group felt that eighty hours was the ideal number, while 41% thought that even eighty hours represented too many duty hours. These findings can be compared with those of Underwood et al. who surveyed a group of eighty-six surgeons, of whom two-thirds were senior surgical residents and one-third were junior-level attending physicians11. Most respondents (74.4%) indicated that a work-week of eighty-one hours or greater was ideal, while only 25.6% felt that a work-week of eighty hours or less was optimal. These findings demonstrate a common theme, whereby junior surgical residents, who are being trained in a new era of duty-hour restrictions and concerns about lifestyle and resident well-being, tend to be more in favor of shorter duty weeks. This is in contrast to the attitudes of their more senior resident and attending counterparts, who are products of an era of unrestricted duty hours that paid little regard to resident lifestyles. Therefore, it appears that the new duty-hour rules are in agreement with the attitudes of a younger generation of surgeons who place greater value on personal well-being and lifestyle than did previous generations.
A second conclusion to be drawn from the data in the present study is that most orthopaedic surgery residents are using self-reporting systems to log duty hours. The respondents in our survey reported a high rate of intentional underreporting of duty hours. These findings call into question the accuracy and usefulness of such self-reporting systems. A report by Saunders et al., in 2005, indicated a high rate of discrepancy in the number of work hours documented when resident self-reporting systems were compared with a more rigorous, electronic swipe-card system12. In a recent study conducted by the American Medical Association, 69% of the 1010 residents reported that they knew how to report excessive hours, but only about half stated that they would feel comfortable doing so13. In the current study, one-third of the respondents had intentionally underreported duty hours on at least one occasion, and only 1% reported the use of more rigorous hour-log systems such as swipe cards. Despite this, more than three-fourths of the respondents felt that their home institutions were utilizing effective duty-hour measurement systems. The current regulations allow the eighty hours of duty per week to be averaged over a four-week period. Therefore, although residents on occasion may be on duty for longer hours, their averages may fall within the compliance range. However, these findings should point to the possibility that residents may not be comfortable reporting excessive duty hours and that a number of orthopaedic training programs are not yet in compliance with the eighty-hour rules. This survey also raises concern that a detailed review of residency programs may reveal duty-hour violations that could result in penalties or citations.
The third major conclusion that can be drawn from our data is that orthopaedic residencies, similar to other training programs, are predominantly using physician extenders, moonlighters, night-float systems, and increased home-call assignments to comply with the new rules. Several other reports in the literature have documented that surgical and nonsurgical disciplines alike have utilized these same strategies to comply with the duty rules8,10,14-16. Although strategies such as physician's assistants and moonlighters may appear to be obvious and easy solutions to the duty-hour rules, such ancillary services carry with them a substantial cost burden that will be increasingly difficult for many orthopaedic departments to absorb.
Another insight to be gained from the data in the present study is that, among orthopaedic surgery subspecialty services, residents on an orthopaedic trauma service experience the most difficulty in complying with the duty rules. This is likely due to the unpredictable and complex nature of trauma care at academic medical centers. Coordinating and administering the required care for their patients often disrupts the ability of residents to participate in the sign-out process and entices or compels the residents to remain in the hospital after being on call. General surgery trauma services and neurosurgical trauma services have also had similar difficulties complying with duty restrictions14,17. The effects of duty-hour restrictions on continuity of care and, ultimately, on patient safety are as yet unknown. However, these findings suggest that some collaboration and cooperation among orthopaedic, general surgery, and neurosurgical trauma services to devise efficient systems to care for the complicated injuries of trauma patients may yield novel compliance strategies.
The final major conclusion that can be drawn from the current study is that, similar to other specialties, the effects of restricted duty hours on the surgical and other educational experiences of orthopaedic residents are currently unknown. In the present study, both junior and senior residents indicated that approximately 70% of the average duty week consisted of educationally valuable time. However, nearly a quarter of the orthopaedic residents also felt that the new rules caused deficits in learning and training experiences. The current literature contains many reports that attempt to assess the effects of the duty rules on resident education. The literature is mixed regarding changes imposed on surgical case volume by these requirements18-20. Reports have also shown that the performance of junior residents on in-training examinations has improved after implementation of the work rules21. Our study does not resolve this important question, but it does provide substantially more cross-sectional data than previous reports10,22. Further evaluation is needed to determine the effects of duty-hour restrictions on resident education, both as demonstrated on examinations as well as through the quality of patient care. It is conceivable that residents of all specialties will have a decreased quantity of educational experiences under the new rules; however, these same, better-rested, and more attentive residents may have more quality experiences in conferences and during operative cases. Future research is required to answer these questions more definitively.
In summary, this report provides insight into the attitudes of orthopaedic surgery residents toward the new duty rules. It also provides evidence that many years and much additional research will be required to fully delineate the myriad effects that the new ACGME rules will have on patient care, house staff well-being, and residency training in the United States.
A copy of the survey that was distributed to orthopaedic residents is 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 Sylvia I. Watkins-Castillo, PhD, and Jim Frankowski of the Department of Research and Scientific Affairs as well as Jeanie Kennedy, Regulatory Affairs Manager, of the American Academy of Orthopaedic Surgery for their help in the preparation, dissemination, analysis, and review of the data presented in this manuscript.
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than $10,000 from the American Academy of Orthopaedic Surgeons. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. Commercial entities (Stryker, DePuy, Synthes, Zimmer, EBI, Stryker Biotech, and Smith-Nephew) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
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