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

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

Current 2011Maximum hours of work per week

80 hours, averaged over 4 wks No No 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-hrremaining hrs for transition and educational activities)• PGY-1 : 16 hrs

Maximum in-hospital on call frequency

Every third night, on average Every third night, no averaging

Minimum time off betweenscheduled 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 addressed 6 consecutive nights

Mandatory time off duty 4 days off per month1 day (24 hours) off per week, averaged over 4 weeks

No change

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

Table 1. General Program Information

Academic year 2009

Accredited programs 246

Number of Community Programs 133

Number of University Programs 104

Military 9

Resident work hours (PGY1)

Average hours on duty per week 75.7

Average maximum consecutive hours on duty 27.3

Average days off duty per week 1.1

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.

Table 3: Changes in Average Number of Cases: U.S. General Surgery Residents

Categories Average Change p value

Skin and soft tissues 0.81 0.32Head and Neck 0.28 0.12Breast 1.91 0.894Alimentary tract 8.19 0.00*Abdomen 8.48 0.000*Vascular 4.03 0.021*Endocrine 0.65 0.25Hand -0.35 0.03*Thoracic 0.80 0.31Pediatric 0.80 0.31Genito-urinary -0.23 0.04*Gynecology -0.37 0.03*Plastic 0.07 0.08Orthopaedics -0.39 0.03*Organ transplant -0.11 0.05*Trauma 0.93 0.38Endoscopy 2.72 0.34Laparoscopic/Thoracoscopic 6.02 0.00*

Weighted Average Change 1.78 0.07

Table 2: Changes in Average Number of Cases: Easton Hospital General Surgery Residents

Categories Average Change p value

Skin and soft tissues -0.58 0.70Head and Neck -0.78 0.64Breast -3.62 0.022*Alimentary tract -1.08 0.54Abdomen -6.29 0.000*Vascular -3.98 0.010*Endocrine -0.11 0.82Hand -0.17 0.80Thoracic 0.14 0.87Pediatric -0.77 0.64Genito-urinary -0.83 0.62Gynecology -0.49 0.72Plastic 0.06 0.85Orthopaedics -0.48 0.72Organ transplant -0.16 0.81Trauma 0.26 0.89Endoscopy -3.53 0.03*Laparoscopic/Thoracoscopic -0.01 0.84

Weighted Average Change -1.20 0.51

700750800850900950

1000105011001150

2003 2004 2005 2006 2007 2008 2009

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

ABDOMEN

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Fig 2: Trends among Subcategories

Table 5: Divergence in Trends between Surgical Residents at and the (2005-2009)

Categories Easton Hospital U.S. Residents p value

Skin and soft tissues -0.84 0.81 0.86Head and Neck -0.91 0.28 0.90Breast -8.62 1.91 0.027*Alimentary tract -3.75 8.19 0.21Abdomen -2.03 8.48 0.002*Vascular -3.47 4.03 0.012*Endocrine -2.32 0.65 0.85Hand 2.45 -0.35 0.76Thoracic -3.20 0.80 0.98Pediatric 0.93 0.80 0.98Genito-urinary -0.97 -0.23 0.76Gynecology -3.06 -0.37 0.97Plastic -0.65 0.07 0.44Orthopaedics -0.29 -0.39 0.94Organ transplant -1.06 -0.11 0.98Trauma -0.16 0.93 0.94Endoscopy 0.56 2.72 0.34Laparoscopic/Thoracoscopic 3.12 6.02 0.73

Total Cases -1.20 1.78 0.027*

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.

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.

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

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 .