Impact of the 80 Hour WorkweekImpact of the 80 Hour Workweek  The role and training of the general surgical resident has perpetually evolved since its inception in the mid- 19th century.  Most recently, the Accreditation Council for Graduate Medical Education’s (ACGME) resident workweek regulations, instituted on July 1, 2003, have been a major influence on the present structure of residency training.

Impact of the 80 Hour WorkweekImpact of the 80 Hour Workweek  The 80-hour work week was created in response to medical educators and the public’s concern for patient safety.  In the field of surgical training, the impact of the new work week regulations on operative experience has become a grave concern, relative to the conventional paradigm.  Although resident quality of life has been reported as improved, there is still much debate as to the effect that the new restrictions will have on general surgery resident education and surgical training.  The impact remains controversial.

Skilled Surgeons-the Legacy Emil Theodor Kocher, M.D. Oscar Ruiz, M.D. Theodore Billroth, M.D. Harvey W. Cushing, M.D. Michael E. DeBakey, M.D.

80 Hour Workweek  “10,000 hour rule” -- Malcolm Gladwell  Key to success in any field is, to a large extent, a matter of practicing a specific task for a total of atleast 10,000 hours.  Surgery is similar to activities such as practicing piano or playing hockey  Need for repetition and consistency  Practice makes perfect. Less practice, …?

Impact of the 80 Hour WorkweekImpact of the 80 Hour Workweek  Numerous studies have been conducted to evaluate the effects of the work week regulation on surgical training.  Conflicting evidence continues to emerge regarding the potential risks and benefits associated with resident duty-hour restrictions.

Cases

Year Cases

Impact of the 80 Hour WorkweekImpact of the 80 Hour Workweek  To be trained as competent surgeons, General Surgery Residents must be exposed to a variety of different operative experiences and must be provided the opportunity to adequately develop their technical skills  Volume and endless repetition

Impact of the 80 Hour WorkweekImpact of the 80 Hour Workweek  To be trained as competent surgeons, General Surgery Residents must be exposed to a variety of different operative experiences and must be provided the opportunity to adequately develop their technical skills  Volume and endless repetition

ACGME Work Hour Restrictions  Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours.  Residents may remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care.  No new patients may be accepted after 24 hours of continuous duty.

ACGME Work Hour Restrictions  Adequate time for rest and personal activities must be provided. This should consist of a 10- hour time period provided between all daily duty periods and after in-house call.  Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities  In-house call must occur no more frequently than every third night, averaged over a four- week period.

80 Hour Workweek  Improves safety and quality of patient care  Improves personal hygiene  Improves the quality of the personal life of residents  Allow time to read/study  Decreases “burnt out” residents

80 Hour Workweek  When the Residency Review Committee considered General Surgery Resident case logs across the country between 1997 and 2004, they found no decrease in the average number of cases performed per resident in the year.  The Committee concluded that resident surgical volume was not affected by the new work-hour restrictions

Study Objective  Now that a 5-year cycle is complete, we sought to test the hypothesis that restrictions on the 80 hour workweek for General Surgery Residents at Riverside Methodist Hospital implemented after July 2003 significantly decreased the volume of operative cases performed by surgical residents, compared to surgical residents at Riverside training prior to July 2003.

Methods  Data were collected from the Accreditation Council for Graduate Medical Education (ACGME) national database and from Riverside Hospital’s General Surgery Residency files for a sampling of academic years before and after the duty-hour changes in surgical education (July 1, 2003).  CPT surgical procedure codes logged by PGY-5 General Surgery residents 15 years before and 5 years after implementation of the 80-hour workweek were compared.  Total General Surgery Department volume per year was also compared to this data.

The Riverside Methodist Hospital General Surgery Residency program accepts two categorical surgical residents each year into a 5-year program, covering a 1000 bed medical center.

Methods  The Riverside Methodist Hospital general surgery residency program accepts two categorical surgical residents each year into a 5-year program.  In addition, an expansion of the program by five categorical residents (one at each postgraduate year [PGY]) was approved by the Residency Review Committee in 2009.

Methods  The outcome variables “PGY-5 Cases” and “Major Cases” (the aggregate number of cases done during their resident tenure) were compared between two study groups defined by the time intervals exclusively before July 2003 (“pre”) and inclusively after July 2003 (“post”).  Statistical analyses included one-sided and two-sided t-tests, non-parametric tests, and t-tests on a 3-parameter logarithmic transformation of the raw data to satisfy normality and equal variance assumptions necessary for t- testing.

Major Cases over 5 years Year 80 Hr

Major Cases over 5 years Major Cases Mean=1395 Mean=953

PGY-5 Cases Year80 Hr Mean # PGY-5 Cases

PGY-5 Cases Mean=345 Mean=257

Summary statistics, tests of assumption of distributional normality and equal variances, and t-test results for the variables “PGY-5 cases” and “Major cases” between groups “pre” and “post”.  The t-tests indicate that the “post” group in fact had fewer “PGY-5 cases” and “major cases” than did the “pre” group  However the t-test results are suspect for these data since the data were not normally distributed and the variances between the “pre” and “post” group were not equal VariableNMean +/- SDF (p-value)Normality PGY-5 cases: Pre Post / / (0.170)SW: 0.006; KS = SW: 0.88 KS=0.15 Major cases Pre Post / / (0.0035)SW: 0.21 KS: SW: 0.96 KS: >0.15 p < for both one-sided and two-sided t-tests. KS=Kolmogorov–Smirnov test, SW=Shapiro–Wilk test

Non-parametric results for the variables “PGY-5cases” and “Major cases” between groups “pre” and “post”. Non-parametric results for the variables “PGY-5 cases” and “Major cases” between groups “pre” and “post”.  Both one-sided and two-sided non-parametric tests indicate statistically significant differences between the “pre” and “post” groups VariableWilcoxon Rank sumMedian scoresSavage scores PGY-5 cases Pre v. post One-tailed Two tailed One-Tailed Two Tailed One-Tailed Two-tailed Major cases Pre v. post One-Tailed Two-tailed One-Tailed Two-tailed One-Tailed Two-tailed

T-test results for 3-parameter log-normal transformations of the variables “PGY-5 cases” (log(cases + 47)) and “Major cases” (log(mcases - 368)) between groups “pre” and “post”.  3-parameter log-normal transformations of the variables normalized the data as well as satisfying the assumption of equal variances in each group, thus making the conclusions valid. VariableNMean +/- SDF (p-value)Normality PGY-5 cases Pre post / / (0.89)SW 0.11 ; KS = 0.15 Major cases: Pre Post / / (0.68)SW: 0.17; KS: >0.15 SW: 0.73; KS: = 0.15 p < for both one-sided and two-sided t-tests. KS=Kolmogorov–Smirnov test, SW=Shapiro–Wilk test

 The slope of the RMH Line was 25.0, meaning that the average increase in RMH total cases per year was 25 (p=0.005).  This trend did not change from the “before” time period to the “after” time period (p=0.2967).

 The trend in resident case experience was estimated for all years (FY89 – FY09). The slope of the line was , meaning that the average decrease in resident case experience per year was 10 cases (p<0.0001).

 There is a decrease in the mean PGY5 resident case experience of cases from the “before” time period to the “after” time period (p=0.0104) [as demonstrated in the previous statistical analysis].

 Upon further examination, there is an “interaction” between the “before vs. after” time period and yearly trend in PGY5 case experience (p=0.0398).  During the “before” time period, there is an average decrease in PGY5 resident case experience of about -7.7 cases per year, while during the “after” time period, there is an average increase of about 11.6 cases per year.

Conclusions  Restrictions dictated by the 80 hour work week for surgical residents at Riverside Methodist Hospital implemented after July 2003 decreased the volume of operative cases performed by surgical residents during both their junior and PGY-5 years, as compared to surgical residents prior to July 2003, determined by non-parametric tests and t-tests on transformed data.  This decrease was not influenced by overall surgical volume

Conclusions/RMH Action  Recognition of the change in culture within the program-  Increase Physician Extenders  Attending coverage of Senior Call  Elimination of Senior “Night-Float”  Attending Mentors- Optimize Quality-time

Implications  The ACGME-mandated 80-hour work week restrictions have challenged surgical educators to creatively reduce work hours while trying to maintain the same high standard of surgical resident education.  There is no easy answer as to how to accomplish this, nor is it yet clear whether the future U.S.-trained general surgeon will have the same level of clinical competence as in the past.  It is incumbent on each individual surgery program to devise strategies to maintain the legacy of excellence in surgical education.

Implications  Without adequate volume and repetition, post 80 hour workweek General Surgery Residents may not be as comfortable to practice independently once their training is complete compared to the pre 80 hour workweek residents  Solutions  Effective use of time during residency  Fellowship  Mentors in practice  Extension of residency if further duty hour restrictions are implemented

ABSITE Influence?