Original reportThe Impact of Work Hour Restrictions on Surgical Resident Education
Introduction
Surgical education has undergone a paradigm shift in the last decade with the consideration and eventual implementation of resident work-hour restrictions. Despite a vast dialogue of concern by practicing general surgeons regarding the long-term implications of these restrictions, many of these changes are still too recent to have had demonstrable effects. The question of who determines a competent surgical resident and how that determination is made remains problematic.1 Much of the initial research investigating these changes has focused on survey data extrapolating resident perceptions of surgical training, surgical case volume, and interactions with attending surgeons as the changes have been executed.2, 3, 4, 5, 6
The American Council of Graduate Medical Education (ACGME) required residency programs in the United States to begin demonstrating compliance with the 80-hour workweek for resident physicians as of July 1, 2003.7 Many programs, including our own, began making plans for this much earlier, integrating new systems designed to limit resident work hours. The ACGME also mandates that residency programs demonstrate competency of their residents throughout their training in various ways. Although no one measurement alone can determine competency, some traditional measurements have been standardized testing and operative volume during training.
The American Board of Surgery In-Training Examination (ABSITE) has traditionally been one measure of academic surgical competency, specifically of basic science and clinical management. All residents in ACGME accredited surgical residency programs take this examination annually. Various studies have shown that programs use the examination for a variety of purposes, including assessment of medical knowledge for competency determinations, promotion to subsequent training level, and in some cases, resident dismissal.8, 9 ABSITE scores are also requested frequently by fellowship program directors, and these data are used in determining offers for many fellowship interviews. On completion of an accredited surgical residency program, graduates must complete the American Board of Surgery Qualifying Examination (ABSQE) within 6 months of graduation. The examination is designed to evaluate knowledge of general surgical and basic science principles applicable to the practice of surgery. Candidates who successfully complete the ABSQE then go on to the Certifying Examination to complete the board certification process.
Work-hour restrictions have also led to significant structural changes in a surgical resident’s operative training. Night float systems, where residents provide shift coverage during the nighttime hours only, have limited effectively the overall number of consecutive hours spent by residents in the hospital. Daily operating room volume has also increased, requiring coverage by ancillary staff such as physician assistants in lieu of residents.3 This increase in operative volume and the concomitant decrease in resident work hours have led to concern about the operative volume experience of graduating general surgery residents.
We chose to investigate the effects of the 80-hour workweek on residents’ academic and clinical education during residency by evaluating ABSITE score, ABSQE score, and operative volume. We hypothesized that total scores and basic science scores on the ABSITE would increase, reflecting the greater time residents would have to engage in didactic study, and clinical management scores would decrease, indicative of reduced time spent directly involved in patient care. We hypothesized further that reduced resident work hours would negatively impact operative volume during training, possibly lowering ABSQE scores after graduation.
Section snippets
Methods
ABSITE scores were reviewed for all residents in our program from 1997 through 2005 and analyzed based on postgraduate year (PGY) level both before and after the work-hour restrictions took effect. Linear mixed-effects models were fitted to percentage correct and percentile for each of the 3 ABSITE scores: Total Score, Basic Science, and Clinical Management.10 Because of the high correlation between percentage correct and standardized score in all 3 ABSITE modalities, no models were sought for
Results
We first evaluated the ABSITE standardized total scores and compared them with the percentile scores for each component score regardless of year of training. The standardized score and percentile score correlated directly, with upper-level residents scoring higher than lower-level residents, thus reinforcing the internal validity of the ABSITE (Fig. 1). Because of the high degree of correlation of ABSITE score with PGY level, each score (percent correct and percentile for basic science and
Discussion
When the ACGME mandated a limit to work hours for resident physicians in July 2003, the long-term effects of such a change were not known. This paradigm shift, brought about by public concerns over patient safety and quality of resident education, was particularly felt by surgical residency educators who traditionally had relied on long work hours as a means to instill a strong work ethic and patient responsibility. Despite practicing surgeons’ concerns about developing competent general
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