1. Local and national trends in general surgery residents’ operative experience: Do work hour limitations negatively affect case volume in small community-based programs? Local and national trends in general surgery residents’ operative experience: Do work hour limitations negatively affect case volume in small community-based programs? Alexey Markelov MD, Aniket Sakharpe MD, Harjeet Kohli MD, David Livert MD Easton Hospital, Drexel University School of Medicine, Easton, PA

2. Introduction  The Accreditation Council for Graduate Medical Education implemented mandatory work hour limitations in July 2003.  New work hour regulations coming in July 2011  Particular concern about potential negative impact on surgical subspecialties due to limited time to acquire necessary surgical proficiency and skills

3. Current2011 Maximum hours of work per week 80 hours, averaged over 4 wks NoNo change Maximum duty period length 30 hours (admitting patients up to 24 hours then 6 additional hours for transitional and educational activities) PGY-2 and above: 28 hrs (admitting patients for up to 24 hrs, plus 4-hr remaining hrs for transition and educational activities) PGY-1 : 16 hrs Maximum in-hospital on call frequency Every third night, on averageEvery third night, no averaging Minimum time off between scheduled duty periods 10 hours after shift length PGY-1 should have 10 hrs; Intermediate-level should have 10hrs; Must have 14 hrs after 24 hrs on in-house duty Final years: exceptions made by RRC Maximum frequency of inhospital night float Not addressed6 consecutive nights Mandatory time off duty4 days off per month 1 day (24 hours) off per week, averaged over 4 weeks No change

4. Introduction  Several papers claimed decrease in total number operative cases performed by graduating residents (Feany et al, Kairys et al), whereas other studies failed to reveal statistically significant difference (Bland et al, Simien et al).  No studies specifically investigated changes in residents’ operative experience in small community- based programs

5. Table 1. General Program Information Academic year2009 Accredited programs246 Number of Community Programs133 Number of University Programs104 Military9 Resident work hours (PGY1) Average hours on duty per week75.7 Average maximum consecutive hours on duty27.3 Average days off duty per week1.1

6. Methods  We retrospectively analyzed annual ACGME generated national and comparative operative log reports for from 2005 to 2009 academic years  Data obtained from Easton Hospital General Surgery residency program operative log reports (years 2002- 2009) was used for comparison.  In order to increase the statistical power of the study Hierarchical Linear Modeling (HLM) technique was utilized to estimate the overall trend across procedures and deviation of each subcategory from the overall trend.

7. Table 3: Changes in Average Number of Cases: U.S. General Surgery Residents CategoriesAverage Changep value Skin and soft tissues0.810.32 Head and Neck0.280.12 Breast1.910.894 Alimentary tract8.190.00* Abdomen8.480.000* Vascular4.030.021* Endocrine0.650.25 Hand-0.350.03* Thoracic0.800.31 Pediatric0.800.31 Genito-urinary-0.230.04* Gynecology-0.370.03* Plastic0.070.08 Orthopaedics-0.390.03* Organ transplant-0.110.05* Trauma0.930.38 Endoscopy2.720.34 Laparoscopic/Thoracoscopic6.020.00* Weighted Average Change1.780.07

8. Table 2: Changes in Average Number of Cases: Easton Hospital General Surgery Residents CategoriesAverage Changep value Skin and soft tissues-0.580.70 Head and Neck-0.780.64 Breast-3.620.022* Alimentary tract-1.080.54 Abdomen-6.290.000* Vascular-3.980.010* Endocrine-0.110.82 Hand-0.170.80 Thoracic0.140.87 Pediatric-0.770.64 Genito-urinary-0.830.62 Gynecology-0.490.72 Plastic0.060.85 Orthopaedics-0.480.72 Organ transplant-0.160.81 Trauma0.260.89 Endoscopy-3.530.03* Laparoscopic/Thoracoscopic-0.010.84 Weighted Average Change-1.200.51

9. Fig 1: Trend for average number of cases over 5 year period

10. Fig 2: Trends among Subcategories

11. Table 5: Divergence in Trends between Surgical Residents at and the (2005-2009) CategoriesEaston HospitalU.S. Residentsp value Skin and soft tissues-0.840.810.86 Head and Neck-0.910.280.90 Breast-8.621.910.027* Alimentary tract-3.758.190.21 Abdomen-2.038.480.002* Vascular-3.474.030.012* Endocrine-2.320.650.85 Hand2.45-0.350.76 Thoracic-3.200.800.98 Pediatric0.930.800.98 Genito-urinary-0.97-0.230.76 Gynecology-3.06-0.370.97 Plastic-0.650.070.44 Orthopaedics-0.29-0.390.94 Organ transplant-1.06-0.110.98 Trauma-0.160.930.94 Endoscopy0.562.720.34 Laparoscopic/Thoracoscopic 3.12 6.020.73 Total Cases -1.20 1.780.027*

12. Results  Comparing the national trend to the community hospital we see that there is total increase in cases at the national level while there is decrease in case volume at the community hospital.  Statistically significant decrease (p<0.05) in number of genitourinary (-0.83), gynecology (-0.37) and orthopedics (-0.39) cases performed by residents was seen throughout the country.

13. Discussion  Preservation of educational experience in majority of the programs nationwide becomes possible due to variety of institutional modifications.  Nuthalapaty et al found that 98% of respondents in obstetrics and gynecology training programs reported modifications to program structure.

14. Discussion  Due to traditionally smaller number of residents in the program, community-based programs cannot easily implement certain structural changes: - night float system - restructuring call schedule (decreasing call frequency) - modification of resident assignment to clinical services  Small programs can not afford hiring physician extenders to decrease work load on residents

15. Conclusions  Despite maintaining the level of absolute case volume in resident training programs, there are major trends that have and will continue to alter the operative experience and case mix of surgical trainees.  Work hour restrictions have been favorable for the larger programs, as these programs were able to better integrate the night float system, restructure their call schedule and implement institutional modifications which might be too resource demanding for smaller training programs.