It has now been over 2 years since the Accreditation Council for Graduate Medical Education (ACGME) instituted work-hour limitations in response to public concerns regarding patient safety and resident welfare. These were based in part on New York laws resulting from the Bell Commission evaluation of patient safety and resident fatigue.9,15 The limitations have been described as arbitrary but are more generous than limits in place in many European countries, many of which apply to practicing physicians and those in training.8
Resident work hours are now limited to 80 hours per week averaged over 4 weeks. Residents must go home after in-house call after 24 hours, with 6 hours allowed for transition of care, continuity clinics, or educational activities. The residents must have 1 day free of clinical responsibilities each week as averaged over 4 weeks. Ten hours must be allowed between regular scheduled shifts. In-house call must be no more frequent than every third night.1 The ACGME will evaluate the impact of the work hour restriction and has stated another requirement may follow that may be higher or lower than 80 hours.
With little data collected before the work hour restrictions, it is difficult if not impossible to assess the impact they have had on residency education. Clearly, program faculty, including chairs, program directors, and all who teach residents, have had to make substantial adaptations. The residents have also had to change their behavior. Academic medical centers must provide additional resources at substantial expense for care previously provided by residents.
An earlier survey of program chairmen and residents was performed in order to identify the effect of the work hour restrictions on residency programs.16 Overall, most were of the opinion the new restrictions had a negative impact due to lost educational opportunities and compromised patient care. No improvement in patient safety was noted. A bimodal response from residents was obtained that may have been related to year of training. Written comments expressed concern about negative effects on professionalism.
In order to see if opinions had in fact changed in the subsequent years we again surveyed program chairmen but this time sought opinions from program directors and senior residents from the Residency Leadership Forum (RLP). Were the negative opinions expressed in the first survey moderated by time and experience? We presumed with time, programs and residents had made accommodations to the new requirements and a more positive view of them would be expressed in this survey. Additional questions were asked about particular challenges raised by the new regulations including communication, teamwork, operative experience, and the effect on the faculty. New questions were asked about how the new rules on orthopaedic education influenced professionalism, resident operative experience, continuity of care, patient safety and workload. Last, we queried the group about coping mechanisms including physician extenders, night float, rotation deletion, and home call.
MATERIALS AND METHODS
To gauge the effect of the new rules on orthopaedic education, and specifically to identify particular challenges and unique coping strategies, the American Orthopaedic Association (AOA) undertook a second survey of program directors and chairs and members of the Resident Leadership Forum. Resident Leadership Forum members are senior level residents nominated by their programs who had participated in the jointly sponsored AAOS/AOA forum. We compared these results to the results of an initial survey completed shortly after the work-hour restrictions were instituted.16 We surveyed 229 program directors and chairs of ACGME accredited residencies in orthopaedic surgery and 98 members of the Resident Leadership Forum with an electronic questionnaire designed by the members of the Academic Leadership Group of the AOA and reviewed and modified by the AOA staff. A reminder was sent two weeks following the initial submission.
Questions were written in such a way to elicit the overall effect of the work hour restrictions on the program as well as to solicit information about various effective and ineffective coping strategies. (Appendix 1) Because of disparities noted on the first survey, additional questions were added to provide clarity. In addition to standard responses, written comments were solicited from those surveyed. The early survey indicated a bimodal response from residents in their attitudes towards the work-hour limitations. To verify this, residents and chairs were asked if resident attitudes toward the duty-hour restrictions were neutral, positive, negative, or mixed based on resident level. Some survey questions were added related to unintended consequences of duty-hour restrictions (Table 1). To measure the effect on operative experience, the respondents were asked to comment on the effect of changes on the volume of operative and clinical experience.
The answers to the survey were then tabulated as a percentage of and compared to other responses. These results were later compared to choices made in the earlier survey. Written remarks were solicited separately in order to allow respondents to comment on related issues beyond what was contained in the survey responses. These were used to determine if common themes were present and if major issues were not addressed by the survey. (The methods and findings have been previously published16 and are republished here in modified form.)
In comparison to the responses from the first survey, there were fewer strong negative opinions and a positive trend indicating some moderation and acceptance of the new regulations (Fig 1). Overall, however the general effect of the work-hour restrictions on orthopaedic residency education programs was described as negative by 61% of the responding program directors and chairs. Most believed this was a minimal effect. A few programs noticed no effect, and 24% thought the new regulations had a positive effect. In comparison, 38% of residents thought the changes had been good for the program, 12% were neutral, and 50% thought the effect was negative. One-half of the program directors and chairs and 58% of the residents believed attitudes were mixed based on resident level. Junior residents view the changes more favorably than more senior level trainees.
Problems related to communication and teamwork in patient hand-offs were commonly cited in the majority of resident and faculty surveys (Table 1). These problems may have in part mitigated any improvements perceived in patient safety as a result of the work hour limitations. An increased number of operative cases without resident involvement was also noted by program directors and residents. Of program directors, 42% thought residents had an inadequate volume of cases; 41% of residents agreed. The majority of program directors and chairs believed the faculty workload had increased. This perception was not shared by the residents. Faculty attitudes towards the work-hour restrictions were described as negative in 57% of program directors' and chairs' responses, neutral in 36%, and positive in 3%. Faculty attitudes were believed to be negative in 47% of the residents' responses, 37% believed the changes had a neutral effect on faculty attitudes, and 10% were described as positive.
Most (65%) residents believed the requirements resulted in improved resident satisfaction and contentment. Program directors and chairs did not share this assessment as strongly (Fig 2). Neither group believed residents were better prepared for cases and examinations, complained less, demonstrated improved teamwork, or were more attentive than they had been before the restrictions. The respondents were of the impression in-training examination scores and resident evaluations have not been affected by the work-hour limitations. No objective data was requested or available.
Addressing the issue most commonly cited for the regulations, patient safety, only 9% of program directors and 31% of residents agreed the changes made to accommodate the work-hour restrictions had resulted in fewer medical errors. Many believed the effect was neutral (30% and 39%). Sixty-one percent of directors and 30% of residents disagreed, saying the limitations had not resulted in fewer errors (Fig 3).
The most common reported adaptation to the work-hour restrictions was using physician extenders, such as physician assistants and similarly trained professionals (76%). This increased from the 51% previously reported. Interestingly, only 56% of the residents noted this accommodation. Not only were more departments using physician extenders, but the survey also showed an increased number of physicians' assistants and nurses hired in each institution, with 27% hiring three or more of these individuals. There was little change in the number of programs using other strategies. Thirty-seven percent of programs have changed call responsibilities from in-house to home call. This relieves the program of assessing the in-house call responsibilities and is fairly straightforward to implement but requires substantial oversight. Time spent in the hospital on-call still counts towards the work-hour limitations. The ACGME has had to subsequently comment on what is meant by home call. Other reported strategies included the design of night float rotations, where the residents' primary task is to assume night call responsibilities (34%). The educational value of this type of rotation varied based on the type of practice, the availability of conferences, and the level of supervision available after hours.
Written comments were largely negative towards the work-hour restrictions. Most mentioned concerns regarding the 30-hour restriction on continuous in house duty because residents are not able to participate in many procedures on patients they have evaluated the night before. This appears to affect mostly residents in the junior years. Also noted was a relative increase in operative trauma cases compared with other mostly elective orthopaedic subspecialty procedures. Some program directors also complained of a shift mentality among the residents, more work for faculty members and senior residents, and challenges related to funding, availability, and using physician extenders. Problems were reported with the adoption of a night float rotation. Most importantly, program directors reported a problem with continuity of care. Positive comments included more rested residents improved lifestyle and morale. Program directors report an increased awareness of the effects of sleep deprivation. In addition, some commented the regulations forced them to address the various resident rotations' educational value and change or remove those not meeting the needs of the program.
The AOA received 94 responses (40% response rate) from program directors and chairs. Although not a majority, it was a larger number than those responding to the first survey. Fifty-nine out of 98 (60%) of the residents completed the questionnaire.
The decision of the ACGME to regulate work hours has had an impact on graduate medical education. Although legislation had already been in effect in the state of New York, the announcement of the proposed work-hour restrictions by the accrediting body caused hospitals, medical schools, and academic departments nationwide to rapidly arrive at strategies to accommodate the necessary changes. Surgical programs in particular were challenged because of the personality, culture, and educational needs of the residents.4,6 The AOA used two surveys to study the early effects of the work-hour restrictions on orthopaedic residency education.
The program directors had a largely negative reaction to the work-hour restrictions. These sentiments appear to be softening with time. There are administrative problems in the implementation of necessary changes and in the documentation of compliance. Faculty members are asked to be more available than in the past and to be involved in patient care, often without resident involvement. Faculty attitudes toward the new rules are seen as negative by program directors and residents. Our findings are very similar to others. A single institution surveyed general surgery and surgical subspecialty faculty, including orthopaedic surgeons, and found 47% of faculty believed their work hours had increased. However, an increase in work hours could not be verified in comparing previously collected data to data collected 6 months after the implementation of the work-hour restrictions.24
Resident attitudes towards the work-hour restrictions were mixed based on postgraduate level. Senior level residents share the concerns and overall negative impressions of many faculty, which has been noted in studies of other specialties.23 Junior level residents, not exposed to years without work-hour restrictions, may be better rested, more content, and have a better lifestyle. Other studies have also shown this result.7,10,18,25
More importantly, many faculty are concerned about the effect of the restrictions on the development of the resident as a professional whose commitment to their patients is paramount. Responsibility and accountability are essential characteristics of the physician.6,13 There is concern residents educated in an atmosphere of restricted work hours will be poorly prepared for the practice of medicine, which, at times, requires long hours and an ability to work despite fatigue.17 The criticism noted most frequently in this survey related to the work-hour restrictions themselves was the 24 plus 6 mandate requiring residents go home after 30 hours of continuous duty. Many commented this restriction had a deleterious effect on education and was not consistent with the practice of orthopaedic surgery. It precluded resident involvement in educational activities, including operative procedures on patients evaluated by the resident the night before. Faculty are also concerned residents and physicians of the future will consider themselves shift-workers.9 Given the popularity of certain subspecialties, such as emergency medicine, anesthesiology, and radiology, it is more likely this goes beyond the issue of work hours and involves generational differences between faculty members and the residents.
In fact, surgical specialties may see more interested students. In the past, students may have been interested in the field but sought other opportunities because of the traditional perception surgical training programs were too rigorous for all but those with a willingness to sacrifice a personal life and work long hours. The duty hour restrictions may change this perception. Recent National Resident Matching Program match information, showing an increased number of American medical graduates seeking positions in general surgery residencies and subspecialties like plastic surgery, may support this hypothesis but it is not proven.19 One study indicated the duty hour restrictions have had a positive impact on students' perceptions of surgeons' lifestyles but does not necessarily increase their interest in a surgical career.3
The work-hour restrictions may have additional important workforce implications. Many programs in orthopaedic surgery have attempted to enlarge their residencies in an effort to meet the requirements with variable success. Increases in resident numbers will require an educational rationale, not one based on service. Small programs with few residents or those with multiple sites of practice are particularly challenged to comply with the requirements. An increased number of residents or a consolidation of programs may result.
The effect of the work-hour limitations on education will likely not be known for years to come. Many program directors and residents expressed concern about the lack of clinical experience resulting from the new rules. The impact of the duty-hour restrictions on the number of patient encounters and operative cases in orthopaedic surgery is not known. Many respondents to the survey believed the residents would do fewer cases. At least one study looking at a general surgery resident program suggested the work-hour restrictions had a substantial negative impact on operative experience. This was measured by missed cases as recorded by the on call residents who had to go home the day after call.11 On an individual case basis this may be true. Overall though, early data from the residency review committee after 1 year of implementation in general surgery found no effect of the work-hour restrictions on the overall surgical experience for major cases or for the experience of the chief residents, which was confirmed in an independent study at a single institution.5,14 Some have suggested the reduction in work hours comes at the expense of outpatient clinic experiences rather than operative experience. Spencer found resident participation in out-patient clinic dropped from 66 to 17%.20 It will have to be seen whether there is a negative impact on the residents' operative case load and patient care experience of sufficient severity to warrant additional years of residency training.
In a similar way, there has been insufficient time to measure the restrictions' effect on patient safety. Studies have reported fewer attention errors in residents who get more rest.12 There was no consensus in our survey. Some residents believed there had been a positive impact. When compared with attending surgeons, in many instances, the residents may be closer to and aware of common but relatively minor medical errors in patient management. Most program directors and an equal number of residents disagreed. Many cited problems with communication inherent with frequent turnover of patient care responsibilities. Many program directors and some residents cited the negative impact of the work-hour restrictions on continuity of care as a patient safety issue. This has been noted in other studies looking at the negative effects of work-hour limitations in other specialties.21 In general surgery, 70% of residents perceived problems with continuity of care and 43% believed the quality of care had deteriorated.10 A survey similar to this found 50% of the faculty believed duty-hour restrictions had resulted in worse patient care with only 2% reporting better care.24 This negative perception was higher among general surgeons as compared with other surgical specialists and those attending surgeons who worked over 80 hours per week.
Positive attitudes toward the work hour restrictions were also noted in the survey. The new rules have compelled program directors to carefully evaluate the educational value of each component of the residency program. They have been asked to eliminate noneducational tasks traditionally delegated to house staff, which facilitated their ability to finish their work. These included phlebotomy, patient transportation, film and medical record recovery, and housekeeping among other duties more appropriately performed by others but often not provided on a reliable basis by the academic medical center. In addition, institutional support has been provided to some programs to meet their service needs, although not universally. Residents appear to be better rested and content and may be spending more time on personal development. Similar to the findings of other studies, the respondents to this survey noted no measurable improvement in resident learning documented by improvement in conference participation or evaluations.22
Orthopaedic residency programs have responded to the new regulations in a variety of ways. Most programs have had to make certain adaptations to comply. Most orthopaedic departments have sought support for the recruitment of physician extenders to meet the service needs of the residency program. This survey showed not only had more programs adopted this strategy, but more physicians' assistants and nurses in each department were required than was noted on the first survey. There have been problems in implementing this adaptation. First, there are not a large number of competent individuals with the desire or training to do this type of work. Second, the relatively high salaries and benefits these individuals require creates increased financial burden on departments and, in cases where the medical center provided funds, increased dependency on hospital administration. Many of the program directors and chairs commented on problems related to the lack of institutional support and availability of adequate personnel. In addition, many found physician extenders did not provide the service a resident traditionally had. Often, multiple personnel were necessary to perform the tasks previously performed by a single resident. This further increased costs. Last, many programs lacked the experience to know how to use these individuals in an effective way. Without guidance and protocols, the systems were not in place to allow these practitioners to care for patients independently and many physicians' assistants became underused and dissatisfied.
Many programs chose to change call responsibilities from in-house to home call. This relieves the program of assessing the in-house call responsibilities and is fairly straightforward for many to implement. However, it is a strategy that calls for oversight and may in selected cases increase resident fatigue. In busy trauma centers, the resident may be called so often they may not be able to leave the institution or may be covering a number of institutions. In addition, the frequency of home call may be increased compared with in-house call. The 24 plus 6 rule does not necessarily apply to residents taking home call. All of these factors may mean residents are in fact on call more often, or worse, are driving to and from home or other locations while fatigued.2
The use of night float rotations to provide night service is another coping strategy used by many programs. The residents at times enjoy relative independence and there may be some improved continuity of care if the rotation is structured so residents consistently follow the same patients each night. There are, however, important concerns about the educational value of the night float rotation, the lack of attending supervision, and the feeling of alienation by some residents.
Three limitations of the study are the low response rate, selection bias, and the lack of objective data. Program directors and residents have been asked to complete multiple surveys on this topic and others. Many may have chosen not to respond based on the lack of available time or confusion over having already completed the same survey (ie, the earlier survey). The potential result is the responses of those with strong opinions regarding the issue dominate our results. As a result many of the conclusions are at times speculative and not fully evidenced by objective data. Without baseline information a comparison before and after the 80 hour work week is not possible. Future tracking of patient safety measures, OITE and Board scores, operative case logs, and patient satisfaction information may provide more concrete observations to be made about future changes in resident education.
The effects of the work-hour restrictions mandated by the ACGME on residency education and patient safety needs to be continuously assessed. In addition, it is important for the organizations involved in postgraduate education to coordinate their activities to obtain reliable information and convey their findings in a constructive manner. For practicing surgeons, there is a need to be attentive to this process. There are regulating bodies charged with patient protection that may wish to expand work-hour restrictions to all physicians, not just those in training programs.
The author thanks Ms. Veronica Galvan, Ms. Christine Eme, and the staff of the AOA for their assistance in the preparation of this manuscript.
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