The Interventional Arm of the Flexibility In Duty-Hour Requirements for Surgical Trainees Trial: First-Year Data Show Superior Quality In-Training Initiative Outcomes

PURPOSE

With the implementation of strict 80-hour work week in general surgery training, serious questions have been raised concerning the quality of surgical education and the ability of newly trained general surgeons to independently operate. Programs that were randomized to the interventional arm of the Flexibility In duty-hour Requirements for Surgical Trainees (FIRST) Trial were able to decrease transitions and allow for better continuity by virtue of less constraints on duty-hour rules. Using National Surgical Quality Improvement Program Quality In-Training Initiative data along with duty-hour violations compared with old rules, it was hypothesized that quality of care would be improved and outcomes would be equivalent or better than the traditional duty-hour rules. It was also hypothesized that resident perception of compliance with duty hour would not change with implementation of new regulations based on FIRST trial.

METHODS

Flexible work hours were implemented on July 1, 2014. National Surgical Quality Improvement Program Quality In-Training Initiative information was reviewed from July 2014 to January 2015. Patient risk factors and outcomes were compared between institutional resident cases and the national cohort for comparison. Residents' duty-hour logs and violations during this period were compared to the 6-month period before the implementation of the FIRST trial. The annual Accreditation Council for Graduate Medical Education resident survey was used to assess the residents' perception of compliance with duty hours.

RESULTS

With respect to the postoperative complications, the only statistically significant measures were higher prevalence of pneumonia (3.4% vs. 1.5%, p < 0.05) and lower prevalence of sepsis (0% vs. 1.5%, p < 0.05) among cases covered by residents with flexible duty hours. All other measures of postoperative surgical complications showed no difference. The total number of duty-hour violations decreased from 54 to 16. Had the institution not been part of the interventional arm of the FIRST trial, this number would have increased to 238. The residents' perception of compliance with 80-hour work week from the Accreditation Council for Graduate Medical Education survey improved from 68% to 91%.

CONCLUSIONS

Residents with flexible work hours on the interventional arm of the FIRST trial at our institution took care of a significantly sicker cohort of patients as compared with the national dataset with equivalent outcomes. Flexible duty-hour policy under the FIRST trial has enabled the residents to have fewer work-hour violations while improving continuity of care to the patients. Additionally, the overall perception of resident compliance with the duty-hour requirements was improved.

Staff Efficiency Trends Among Pediatric Hospices, 2002-2011

This study provided the first examination of staff efficiency trends among pediatric hospices. Although pediatric staff efficiency demonstrated large variability from 2002 to 2011, the general trend in efficiency from 2003 to 2010. The decline in efficiency means, on average, pediatric hospices had higher operating expenses and used more capacity, but greater amounts of these greater outputs as measured by visits per patient. The study also highlights the crucial role pediatric hospice nurse managers play in developing effective workforce strategies that allow for responsive changes to workload fluctuations. Due to the associations between efficiency, regulation, and growth, nurse leaders' abilities to develop effective strategies are more imperative than ever to ensure quality end-of-life care for children and their families.

Finding the elusive balance between reducing fatigue and enhancing education: perspectives from American residents

Duty hour restrictions for residency training were implemented in the United States to improve residents' educational experience and quality of life, as well as to improve patient care and safety; however, these restrictions are by no means problem-free. In this paper, we discuss the positive and negative aspects of duty hour restrictions, briefly highlighting research on the impact of reduced duty hours and the experiences of American residents. We also consider whether certain specialties (e.g., Emergency Medicine, Radiology) may be more amenable than others (e.g., Surgery) to duty hour restrictions. We conclude that feedback from residents is a crucial element that must be considered in any future attempts to strike a balance between reducing fatigue and enhancing education.

Perspectives on the working hours of Australian junior doctors

The working hours of junior doctors have been a focus of discussion in Australia since the mid-1990s. Several national organizations, including the Australian Medical Association (AMA), have been prominent in advancing this agenda and have collected data (most of which is self-reported) on the working hours of junior doctors over the last 15 years. Overall, the available data indicate that working hours have fallen in a step-wise fashion, and AMA data suggest that the proportion of doctors at high risk of fatigue may be declining. It is likely that these changes reflect significant growth in the number of medical graduates, more detailed specifications regarding working hours in industrial agreements, and a greater focus on achieving a healthy work-life balance. It is notable that reductions in junior doctors' working hours have occurred despite the absence of a national regulatory framework for working hours. Informed by a growing international literature on working hours and their relation to patient and practitioner safety, accreditation bodies such as the Australian Commission on Safety and Quality in Health Care (ACSQHC) and the Australian Medical Council (AMC) are adjusting their standards to encourage improved work and training practices.

Managing and mitigating fatigue in the era of changing resident duty hours

The medical establishment is grappling with the complex issue of duty hour regulations - an issue that is a natural consequence of the numerous changes in medical culture and practice that have occurred over the course of decades. Sleep deprivation resulting from long duty hours has a recognized impact on resident health and wellness. This paper will briefly outline the evolution of the concept of well-being in residency, review the specific theme of fatigue management within that context, and describe strategies that may be used to mitigate and manage fatigue, as well as approaches that may be taken to adapt to new scheduling models such as night float. Finally, the paper will call for a change in the culture in our workplaces and among our residents and faculty to one that promotes good health and ensures that we maintain a fit and sustainable medical workforce.

Resident duty hours around the globe: where are we now?

Safe and appropriate health care, especially in urgent or emergency situations, is the expectation of the public throughout the developed world. Achieving this goal requires appropriate levels of medical and other staff, appropriate training, and sensible working hours. Too often the brunt of such care, especially in out-of-hours situations, is borne by medical residents, who--to make matters worse--are frequently poorly supervised by more senior and experienced staff. Many jurisdictions have been alerted to this problem and are striving to correct it. However, the variation in attempts to restrict the actual hours worked by residents to "safe" levels is enormous, and all too often there is no consensus as to what should be put in place to achieve safe patient care. This paper sets out the current position for Europe, North America, and Australia.

Effects of the reduction of surgical residents' work hours and implications for surgical residency programs: a narrative review

BACKGROUND

The widespread implementation of resident work hour restrictions has led to significant alterations in surgical training and the postgraduate educational experience. We evaluated the experience of surgical residency programs as reflected in the literature from 2008 onward in order to summarize current challenges and identify key areas in need of further research.

METHODS

We searched MEDLINE and EMBASE for English-language articles published from January 2008 to December 2011 related to work hour restrictions in surgical residency programs, including those pertaining to personal well-being, education and training, patient care, and faculty experiences.

RESULTS

We retrieved 240 unique abstracts and included 24 studies in the current review. Of the 10 studies examining effects on operating room experience, 4 reported negative or mixed outcomes and 6 reported neutral outcomes, although non-compliance was demonstrated in 2 of these studies. Effects on surgical faculty perceptions were consistently reported as negative, while the effect on patient outcomes and professionalism were found to be neutral and unchanged.

CONCLUSIONS

Further studies are needed to characterize operative experience at varying levels of training, particularly in the context of strict adherence to new work hours. Research that examines the effect of the work hour limitations on professionalism and non-operative educational activities, such as reading and simulation-based training, as well as sign-over practices, would also be of benefit.

Duty hours as viewed through a professionalism lens

Understanding medical professionalism and its evaluation is essential to ensuring that physicians graduate with the requisite knowledge and skills in this domain. It is important to consider the context in which behaviours occur, along with tensions between competing values and the individual’s approach to resolving such conflicts. However, too much emphasis on behaviours can be misleading, as they may not reflect underlying attitudes or professionalism in general. The same behaviour can be viewed and evaluated quite differently, depending on the situation. These concepts are explored and illustrated in this paper in the context of duty hour regulations. The regulation of duty hours creates many conflicts that must be resolved, and yet their resolution is often hidden, especially when compliance with or violation of regulations carries significant consequences. This article challenges attending physicians and the medical education community to reflect on what we value in our trainees and the attributions we make regarding their behaviours. To fully support our trainees’ development as professionals, we must create opportunities to teach them the valuable skills they will need to achieve balance in their lives. [P]rofessionalism has no meaningful existence independent of the interactions that give it form and meaning. There is great folly in thinking otherwise. Hafferty and Levinson (2008)[1] Understanding and evaluating professionalism is essential to excellence in medical education and is mandated by organizations that oversee medical training [2]. Historically, attention has been focused largely on the professionalism of individual students or residents, at least for the purposes of evaluation. Yet there is now a growing appreciation that professionalism can be defined, understood, and evaluated from multiple perspectives [3]. Importantly, context has been recognized as critical to shaping trainees’ behaviours, and hence as important to our understanding of them [4]. A restriction in duty hours for trainees is clearly an important environmental and contextual factor to consider in evaluating professional behaviour. In this paper I will review some key issues with respect to understanding and evaluating professionalism, and then discuss these in the context of duty hour reform. Readers should note that this is not intended to be a comprehensive review of the literature of either professionalism or duty hour reform, but rather a critical narrative review that uses selected articles.

Building continuity in handovers with shorter residency duty hours

As junior doctors work shorter hours in light of concerns about the harmful effects of fatigue on physician performance and health, it is imperative to consider how to ensure that patient safety is not compromised by breaks in the continuity of care. By reconceptualizing handover as a necessary bridge to continuity, and hence to safer patient care, the model of continuity-enhanced handovers has the potential to allay fears and improve patient care in an era of increasing fragmentation. "Continuity-enhanced handovers" differ from traditional handovers in several key aspects, including quality of information transferred, greater professional responsibility of senders and receivers, and a different philosophy of "coverage." Continuity during handovers is often achieved through scheduling and staffing to maximize the provision of care by members of the primary team who have first-hand knowledge of patients. In this way, senders and receivers often engage in intra-team handovers, which can result in the accumulation of greater common ground or shared understanding of the patients they collectively care for through a series of repeated interactions. However, because maximizing team continuity is not always possible, other strategies such as cultivating high-performance teams, making handovers active learning opportunities, and monitoring performance during handovers are also important. Medical educators and clinicians should work toward adopting and testing principles of continuity-enhanced handovers in their local practices and share successes so that innovation and learning may spread easily among institutions and practices.

Scheduling in the context of resident duty hour reform

Fuelled by concerns about resident health and patient safety, there is a general trend in many jurisdictions toward limiting the maximum duration of consecutive work to between 14 and 16 hours. The goal of this article is to assist institutions and residency programs to make a smooth transition from the previous 24- to 36-hour call system to this new model. We will first give an overview of the main types of coverage systems and their relative merits when considering various aspects of patient care and resident pedagogy. We will then suggest a practical step-by-step approach to designing, implementing, and monitoring a scheduling system centred on clinical and educational needs in the context of resident duty hour reform. The importance of understanding the impetus for change and of assessing the need for overall workflow restructuring will be explored throughout this process. Finally, as a practical example, we will describe a large, university-based teaching hospital network's transition from a traditional call-based system to a novel schedule that incorporates the new 16-hour duty limit.

Duty hour restrictions: organizational dynamics, systems issues, and the impact on faculty

The potential impact of resident duty hour restrictions on faculty is likely significant; however, the extent of this impact has still not been well documented. We undertook a narrative review of the literature to determine the magnitude of that potential impact and the nature of the evolving discourse related to faculty members as individuals. The literature provides an inconsistent picture of the impact of duty hour restrictions on faculty. While some studies have reported a significant increase in faculty workload, others suggest that the impact of duty hour restrictions has been minimal. Some papers suggest that duty hour restrictions may fundamentally change the nature of resident-teacher interactions and, as a result, will necessitate significant changes to the way education is delivered. Overall, the majority of issues of concern relate to one of the following: volume and composition of work, impact on faculty career choice, evolving perceptions of residents as learners, and the need to find an appropriate balance between learning and the quality and quantity of patient care. In describing these themes we identify some potential solutions and future directions for reconciling duty hour restrictions with faculty perceptions, anxieties, and desired outcomes.