Elsevier

Current Surgery

Volume 61, Issue 6, November–December 2004, Pages 609-611
Current Surgery

2004 APDS spring meeting: Part 2
Meeting the 80-hour work week requirement: What did we cut?

https://doi.org/10.1016/j.cursur.2004.07.010Get rights and content

Objective

To meet the new accreditation requirement, small programs with limited manpower must make hard decisions to safeguard quality. We devised a system to meet the requirement in our own environment, making the obligatory cuts in educational components as prioritized by the trainees. This study examined what aspect of training is impacted and the residents’ perception of the resulting change.

Method

In a fully accredited program where the baseline work hours/week exceeded the new requirement by over 20% even with full deployment of physician’s assistants, the strategies used included reducing external rotations, transitioning PGY-3 into senior responsibility, and integrating senior rotations to 2 hospitals into 1 (2 weeks/month), so that time in a lower volume hospital helped to bring the monthly average to target. Residents were surveyed at 6-month intervals for their perception of the change.

Results

Compared with baseline, the new system averaged 77 ± 5 hours/week, significantly reduced from before (98 ± 12, p < 0.01), but with greatly reduced continuity of care (28 ± 10% vs. 88 ± 8%, p < 0.001), reduced consultations seen (19 ± 4 vs. 36 ± 7 per week, p < 0.001), reduced conference attendance (5.7 vs. 3.5 per week, p < 0.001), and reduced operations (55 ± 7 vs. 68 ± 9 per week for the program). External rotations have been reduced by 3 months, and outpatient clinics merged from 5 to 2. Surveys showed improvement in fatigue-related issues for junior residents. Senior residents were dissatisfied with the reduced educational components.

Conclusion

Reducing work hours cannot be accomplished without reducing educational components. Unlike junior residents, senior residents felt less fulfilled with the new system and do not benefit in physical fatigue.

Introduction

In implementing a work week of no more than 80 hours for all training programs, the arduous deliberation of ACGME with exhaustive coverage of all aspects has been well publicized in their website and bulletins for the past several years. The basic tenet, that reducing physical fatigue and eliminating noneducative tasks may lead to better learning efficiency, fewer errors, and more fulfilling residents, can only be tested after implementation. Considering the differences in specialties, size of programs, types of institutions, and the divergent needs of junior versus senior residents, a “one size fits all” rule would be difficult to put into practice. In particular, for small programs already devoid of noneducational chores, reduction in educational components is an unavoidable sequelae of shorter hours in the hospital. Since the rule has been in effect, many solutions, ranging from reengineered schedules, reduced patient volume, or more manpower (residents or physician assistants), have been devised, but none without major drawbacks.1, 2, 3 In this study, we outline our system of meeting with the rule and analyze the unavoidable side effects, and we report on the outcome of the effort—how the residents feel about the change with respect to work satisfaction and physical fatigue.

Section snippets

Baseline information

In a surgical training program graduating 2 residents per year, with 3 nondesignated preliminary residents, the baseline work hours/week averaged 97 ± 12. The main hospital is a 250-bed community hospital with a level II trauma center. The program has been in good accreditation standing and has no citations in the recent review. The resident manpower has been augmented by a surgical assistant team of 5, with work assigned by the chief resident for full integration. Residents do not perform

Results

As shown in Table 1, the new schedule complied with the 80-hour week for all residents, the hour reduction being less for the juniors. The maximum consecutive hours was reduced by sending residents home at the end of the call duty. For junior residents, reduction in peripheral external rotations has the most direct impact, whereas the other components (operations, consultation, continuity of care, and conferences), all of which are significantly reduced, seemed to affect the senior residents

Discussion

Prior to July 2003, most surgical programs outside of New York State did not meet the new accreditation requirement nor had any systematic tracking of work hours been used. Current systems of meeting with the new rule fall into 3 categories: increasing manpower (adding more residents or physician assistants), reducing work load (limiting teaching service size), and redeployment of existing manpower (eg, “night float” system and other nontraditional scheduling).1, 3 In all of them, some

References (5)

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