Elsevier

Journal of Surgical Education

Volume 67, Issue 5, September–October 2010, Pages 283-289
Journal of Surgical Education

Original report
Impact of the 80-Hour Workweek on Surgical Case Exposure Within a General Surgery Residency Program

https://doi.org/10.1016/j.jsurg.2010.07.012Get rights and content

Objective

The objective of this statistical analysis was to test the hypothesis that implementation of the 80-hour workweek restrictions for General Surgery residents at Riverside Methodist Hospital after July 2003 decreased their operative experience relative to surgical residents trained at Riverside before these changes.

Design, Setting, Participants

Data were collected from the Accreditation Council for Graduate Medical Education national database and from Riverside Methodist Hospital's General Surgery Residency records for a sampling of academic years before and after the duty-hour changes in surgical education (July 1, 2003). Current procedural terminology (CPT) surgical procedure codes logged by postgraduate year (PGY) 5 General Surgery residents 15 years before and 5 years after implementation of the 80-hour workweek were compared. The outcome variables “total major cases” and “Chief cases” were compared between 2 study groups defined by the time intervals exclusively before July 2003 (“pre”) and inclusively after July 2003 (“post”). Hospital general surgical case volume for the study intervals was also tallied. Statistical analyses included 1- and 2-sided t-tests, nonparametric tests, and t-tests on a 3-parameter logarithmic transformation of the data.

Results

Despite an upward trend in total general surgery cases (slope = 25/year, p = 0.005), there was a statistically significant decrease in the operative experience for categorical surgical residents following the 80-hour workweek restrictions. The mean (SD) number of major cases performed by “pre”-restriction residents during their training significantly exceeded that of their “post” cohorts (1395 [326] vs 953 [134], p < 0.001). The training for PGY 5 residents was similarly influenced (345 [81] vs 237 [55], p < .0001).

Conclusions

Despite an increase in the total number of major operative cases available, the volume of cases performed by residents has decreased after implementation of the Accreditation Council for Graduate Medical Education (ACGME) work-hour restrictions. Our data suggest that the impact of the 80-hour workweek has had a detrimental effect on the conventional resident training experience.

Introduction

Numerous historical factors have impacted the evolution of surgical education over the past century. Arguably the most significant restructuring of residency programs in the United States occurred after the implementation of residency work hour restrictions. In response to the release of the Institute of Medicine report on medical errors in 1999, which implicated resident fatigue as a major factor, the Accreditation Council for Graduate Medical Education (ACGME) implemented national mandatory workweek hour restrictions for all residencies. These changes, which took effect on July 1, 2003, include a limit of 80 hours per week, a maximum in-house call duty of every third day, in-house call lasting no longer than 30 consecutive hours, freedom from clinical duties for at least 10 hours after a 24-hour shift, and freedom from clinical responsibilities for 1 out of every 7 days.1 These workweek changes were welcomed by many medical educators as appropriate steps to address the public's concern for patient safety.2, 3, 4 However, there has been much concern raised in regard to the impact of these new regulations on the quality of surgical training, as well as on resident operative volume and experience, given the traditionally long hours of a surgical training program.

Some have argued that surgical residency training will need to be extended to offset the duty hour reduction. Others have advocated creative additions to the traditional educational paradigm, including apprenticeship, mastery, night float, and stretch models.5, 6 We undertook this study to analyze the effects of the 80-hour workweek restriction on our general surgery residency training program at Riverside Methodist Hospital (RMH) 5 years after the implementation of these regulations, relative to the prior 15 years.

Section snippets

Methods

The RMH general surgery residency program accepts 2 categorical surgical residents each year into a 5-year program. In addition, a temporary expansion of the program by 5 categorical residents (1 at each postgraduate year) was approved by the Residency Review Committee in 2009. The additional residents' tenure began after the measured dataset completed in 2008.

Institutional Review Board exemption approval was obtained to access resident records. Data were collected retrospectively from the

Results

Thirty individual resident years before 2003 and 10 resident years after 2003 were available for analysis. The average number of total “major cases” for PGY 5 residents performed before the work hour restrictions (“pre”) were 1394.8 compared with 953.2 after implementation of the 80-hour workweek (“post”), a net decrease of 441.6. Similarly, the mean number of “PGY 5 cases” for the “pre” group was 345 compared with 236.6 of the “post” group, a decrease of 108.4.

The averages of these current

Discussion

Since discussion began regarding work-hour reform, both residents and attending physicians expressed concern that surgical resident training would be negatively impacted because of work hour restrictions. We found evidence of an area within our residency deleteriously affected by these changes. We report decreased surgical exposure for our surgical residents based on the specific criteria of logged current procedural terminology (CPT) codes, even though the volume of identical general surgery

Conclusions

In summary, this study examined the impact of ACGME work hour regulations on the number of major procedures performed by general surgery residents during their training. We noted a statistically significant decrease in the number of major procedures performed by residents during their aggregate training experience as well as their Chief year, after initiation of these parameters. The resident operative and educational experience relative to the impact of ACGME restrictions on duty hours remains

Acknowledgments

The authors have no conflicts of interest regarding this study.

We thank the following people for their contributions, efforts, and input: Lynn Shaffer, PhD, Ohio Health Research and Innovation Institute, Brian Palmer, PhD, Biostatistician, and Elizabeth Fannin, BA, Medical Writer/Editor.

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