Intern call schedules and their relationship to sleep, operating room participation, stress, and satisfaction

Optimizing Surgeon Well-Being: A Review and Synthesis of Best Practices

Through a systematic review and mixed-methods meta-synthesis of the existing literature on surgeon well-being, we sought to identify the specific elements of surgeon well-being, examine factors associated with suboptimal well-being, and highlight opportunities to promote well-being.

Background

Suboptimal surgeon well-being has lasting and substantial impacts to the individual surgeon, patients, and to society as a whole. However, most of the existing literature focuses on only 1 aspect of well-being-burnout. While undoubtedly a crucial component of overall well-being, the mere absence of burnout does not fully consider the complexities of being a surgeon.

Methods

We performed a literature search within Ovid Medline, Elsevier Excerpta Medica dataBASE, EBSCOhost Cumulative Index to Nursing and Allied Health Literature, and Clarivate Web of Science from inception to May 7, 2020, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies with primary data examining surgeon well-being were included. Using a predetermined instrument, data were abstracted from each study and compared using thematic analysis.

Results

A total of 5369 abstracts were identified and screened, with 184 full articles (172 quantitative, 3 qualitative, 9 mixed methods) selected for analysis. Among these, 91 articles measured burnout, 82 examined career satisfaction, 95 examined work-related stressors, 44 explored relationships and families, and 85 assessed emotional and physical health. Thematic analysis revealed 4 themes: professional components, personal components, work-life balance, and impacts to well-being.

Conclusions

Surgeon well-being is complex and multifaceted. This nuanced examination of surgeon well-being highlights the critical need to develop and provide more long-term support to surgeons-with interventions being tailored based on individual, institutional, and systemic factors.

Impact of extended duty hours on medical trainees

Many studies on resident physicians have demonstrated that extended work hours are associated with a negative impact on well-being, education, and patient care. However, the relationship between the work schedule and the degree of impairment remains unclear. In recent years, because of concerns for patient safety, national minimum standards for duty hours have been instituted (2003) and revised (2011). These changes were based on studies of the effects of sleep deprivation on human performance and specifically on the effect of extended shifts on resident performance. These requirements necessitated significant restructuring of resident schedules. Concerns were raised that these changes have impaired continuity of care, resident education and supervision, and patient safety. We review the studies on the effect of extended work hours on resident well-being, education, and patient care as well as those assessing the effect of work hour restrictions. Although many studies support the adverse effects of extended shifts, there are some conflicting results due to factors such as heterogeneity of protocols, schedules, subjects, and environments. Assessment of the effect of work hour restrictions has been even more difficult. Recent data demonstrating that work hour limitations have not been associated with improvement in patient outcomes or resident education and well-being have been interpreted as support for lifting restrictions in some specialties. However, these studies have significant limitations and should be interpreted with caution. Until future research clarifies duty hours that optimize patient outcomes, resident education, and well-being, it is recommended that current regulations be followed.

Pediatric Resident Workload Intensity and Variability

BACKGROUND

Research on resident workloads has focused primarily on the quantity of hours worked, rather than the content of those hours or the variability among residents. We hypothesize that there are statistically significant variations in resident workloads and better understanding of workload intensity could improve resident education.

METHODS

The Stanford Children's Health research database was queried for all electronic notes and orders written by pediatric residents from June 2012 to March 2014. The dataset was narrowed to ensure an accurate comparison among residents. A survey was used to determine residents' self-perceived workload intensity. Variability of total notes written and orders entered was analyzed by χ(2) test and a Monte Carlo simulation. Linear regression was used to analyze the correlation between note-writing and order-entry workload intensity.

RESULTS

A total of 20 280 notes and 112 214 orders were written by 26 pediatric interns during 6 core rotations between June 2012 and June 2013. Both order-entry and note-writing workload intensity showed highly significant (P < .001) variability among residents. "High workload" residents, defined as the top quartile of total workload intensity, wrote 91% more orders and 19% more notes than "low workload" residents in the bottom quartile. Statistically significant correlation was observed between note-writing and order-entry workload intensity (R(2) = 0.22; P = .02). There was no significant correlation between residents' self-perceived workload intensity and their objective workload.

CONCLUSIONS

Significant variations in workload exist among pediatric residents. This may contribute to heterogeneous educational opportunities, physician wellness, and quality of patient care.

Self-perceived sleepiness in emergency training physicians: prevalence and relationship with quality of life

Introduction

Sleep deprivation among training physicians is of growing concern; training physicians are susceptible due to their prolonged work hours and rotating work schedules. The aim of this study was to determine the prevalence of self-perceived sleepiness in emergency training physicians, and to establish a relationship between self-perceived sleepiness, and quality of life.

Methods

Prospective survey in Ibn Sina University hospital Center in Morocco from January to April 2011 was conducted. Questionnaires pertaining to socio-demographic, general, and sleep characteristics were completed by training physician who ensured emergency service during the month preceding the survey. They completed the Epworth sleepiness scale (ESS) which assessed the self-perceived sleepiness, and the EuroQol-5 dimensions (EQ-5D) scale which assessed the general quality of life.

Results

Total 81 subjects (49 men and 32 women) were enrolled with mean age of 26.1 ± 3.4 years. No sleepiness was found in 24.7% (n = 20), excessive sleepiness 39.5% (n = 32), and severe sleepiness in 35.8% (n = 29) of training physicians. After adjusting for multiple confounding variables, four independent variables were associated with poorer quality of life index in training physician; unmarried (ß −0.2, 95% CI −0.36 to −0.02; P = 0.02), no physic exercise (ß −0.2, 95% CI −0.39 to 0.006; P = 0.04), shift-off sleep hour less than 6 hours (ß −0.13, 95% CI −0.24 to −0.02; P = 0.01), and severe sleep deprivation(ß −0.2, 95% CI −0.38 to −0.2; P = 0.02).

Conclusion

Nearly two third of training physicians had suffered from sleepiness. There is an association between poor quality of life and severe sleepiness in unmarried physicians, sleeping less than 6 hours in shift-off day, and doing no physical activity.

Effect of fatigue on laparoscopic skills: a comparative historical cohort study

BACKGROUND

Fatigue has been shown to have a negative impact on surgical performance. However, there is a lack of research investigating its effect on laparoscopy, particularly in Australia. This study investigated whether fatigue associated with a surgeon's usual workday led to a measurable drop off in laparoscopic surgical skills as assessed on a laparoscopic simulator.

METHODS

A comparative study involving two cohorts was undertaken: a study group whose data were collected prospectively was compared to a historical control group. Participants were required to reach a predetermined level of proficiency in each laparoscopic task on either a FLS or LapSim simulator. The participants in the study cohort were re-tested approximately 1 month after completing 10 h of work. The participants in the historical non-fatigued group were re-tested approximately 1 month after reaching proficiency. Comparisons between cohorts were made using a 'decrease in score per day elapsed' value to account for the natural attrition in skills over time and the variability in testing times within and between the two cohorts.

RESULTS

The decrease in overall score per day elapsed for fatigued participants was significantly greater than for historical non-fatigued participants, irrespective of the simulator type. Fatigue had a greater impact on certain laparoscopic skills, including peg transfer and knot tying. Participants who self-reported higher level of fatigue demonstrated significantly better skills than those who self-reported lower levels.

CONCLUSION

Overall laparoscopic skill proficiency was reduced in the fatigued participants compared to the historical non-fatigued participants, with certain laparoscopic skills more affected than others.

Sleep science, schedules, and safety in hospitals: challenges and solutions for pediatric providers

Sleep deprivation is common among resident physicians and clinical fellows. Current evidence about sleep science, performance, shift work, and medical errors consistently demonstrates positive impact from reduction of excessive duty hours, particularly when shift length is shortened. This article provides an overview of this literature, highlighting research on diminished physician cognitive performance due to sleep deprivation and the increase in the number of medical errors that is seen under these conditions. Accreditation Council on Graduate Medical Education trainee duty hour guidelines are reviewed. Practical approaches to evidence-based scheduling of shift-work are also discussed, with attention to improving patient safety.

Effects of fatigue on surgeon performance and surgical outcomes: a systematic review

BACKGROUND

Sleep deprivation and disturbances in circadian rhythms generally lead to poor performance, but is there a link in surgery? This review aimed to determine whether fatigue has an impact on surgeon performance or surgical outcomes.

METHODS

Studies were identified by searching EMBASE, CINAHL, PubMed, The Cochrane Library, Current Contents and clinical trials databases. Inclusion of relevant studies was by application of a predetermined protocol and independent assessment by two reviewers. Each included study was critically appraised for its study quality according to the methods used for Cochrane Reviews. Data from included studies were extracted by one researcher using standardized data extraction tables developed a priori and checked by a second researcher.

RESULTS

From 823 potentially relevant studies, a total of 16 studies were included in this review: two randomized controlled trials, five non-randomized comparative studies and nine case series. Of five studies that directly measure clinical performance, three studies reported no significant difference as a result of sleep deprivation, while two studies found increases in complications or errors. Eleven studies assessed psychomotor skill performance using a variety of simulation-based methods when a participant was rested and/or fatigued. Two randomized controlled trials reported no significant differences, while the nine remaining studies reported mixed results. Surgical residents with less surgical training/experience appeared to be more affected than more senior residents.

CONCLUSION

There is little evidence, as yet, to inform the issue of the effect of fatigue on surgical performance.

Stress management training for surgeons-a randomized, controlled, intervention study

BACKGROUND

Stress and coping influence performance. In this study, we evaluate a novel stress management intervention for surgeons.

METHODS

A randomized control group design was used. Sixteen surgeons were allocated to either the intervention or control group. The intervention group received training on coping strategies, mental rehearsal, and relaxation. Performance measures were obtained during simulated operations and included objective-structured assessment of technical skill, observational teamwork assessment for surgery, and end product assessment rated by experts. Stress was assessed using the state-trait-anxiety-inventory, observer rating, coefficient of heart rate variability (C_HRV), and salivary cortisol. The number of applied surgical coping strategies (number of coping strategies [NC]) was assessed using a questionnaire. A t test for paired samples investigated any within-subject changes, and multiple linear regression analysis explored between-subject effects. Interviews explored surgeons' perceptions of the intervention.

RESULTS

The intervention group showed enhanced observational teamwork assessment for surgery performance (t = -2.767, P < 0.05), and increased coping skills (t = -4.690, P < 0.01), and reduced stress reflected inheart rate variability (t = -4.008, P < 0.01). No significant changes were identified in the control group. Linear regression analysis confirmed a significant effect on NC (β = -0.739, P < 0.01). Qualitative data analysis revealed improved technical skills, decision making, and confidence.

CONCLUSIONS

The intervention had beneficial effects on coping, stress, and nontechnical skills during simulated surgery.

Effects of reducing or eliminating resident work shifts over 16 hours: a systematic review

STUDY OBJECTIVES

The Institute of Medicine (IOM) has called for the elimination of resident work shifts exceeding 16 hours without sleep. We sought to comprehensively evaluate the effects of eliminating or reducing shifts over 16 hours.

DESIGN AND OUTCOME MEASURES

We performed a systematic review of published and unpublished studies (1950-2008) to synthesize data on all intervention studies that have reduced or eliminated U.S. residents' extended shifts. A total of 2,984 citations were identified initially, which were independently reviewed by two authors to determine their eligibility for inclusion. All outcomes relevant to quality of life, education, and safety were collected. Study quality was rated using the U.S. Preventive Services Task Force methodology.

MEASUREMENTS AND RESULTS

Twenty-three studies met inclusion criteria (kappa = 0.88 [95% CI, 0.77-0.94] for inclusion decisions). Following reduction or elimination of extended shifts, 8 of 8 studies measuring resident quality of life found improvements. Four of 14 studies that assessed educational outcomes found improvements, 9 found no significant changes, and one found education worsened. Seven of 11 identified statistically significant improvements in patient safety or quality of care; no studies found that safety or care quality worsened.

CONCLUSIONS

In a systematic review, we found that reduction or elimination of resident work shifts exceeding 16 hours did not adversely affect resident education, and was associated with improvements in patient safety and resident quality of life in most studies. Further multi-center studies are needed to substantiate these findings, and definitively measure the effects of eliminating extended shifts on patient outcomes.

Threat and challenge: cognitive appraisal and stress responses in simulated trauma resuscitations

OBJECTIVES Training and practice in medicine are inherently stressful. Research into the effects of acute stressors has revealed significant variability in individual responses to stressors, with performance impairments occurring in those who demonstrate elevated subjective and physiological responses. Cognitive appraisals (subjective assessment of situational demands and available resources) of a stressor have been proposed as a predictor variable in stress responses. However, the relationship between cognitive appraisal and stress responses has not been tested empirically in complex realistic situations. The purpose of this study was to determine the extent to which cognitive appraisal affects a medical trainee's subjective and physiological stress responses to high-acuity simulated clinical situations. METHODS Thirteen emergency medicine and general surgery residents participated in high (HS) and low (LS) stress trauma resuscitation simulations. Subjective (cognitive appraisal and State-Trait Anxiety Inventory [STAI]) and physiological (salivary cortisol) measures were collected at baseline and in response to participation in each scenario. RESULTS Post-scenario STAI scores, cognitive appraisal and cortisol levels were higher in the HS scenario compared with the LS scenario. For the participants who appraised the scenarios as 'threats' (in which the demands outweighed the resources), the ratio of perceived demands to resources was positively correlated with cortisol levels (r = 0.59, p < 0.05) and STAI responses (r = 0.64, p < 0.05). By contrast, for the participants who appraised the scenarios as 'challenges' (in which resources were sufficient to meet the demands), the perceived ratio of demands to resources was not correlated with either the STAI scores or cortisol levels. CONCLUSIONS Subjective appraisals of a situation appear to play an important role in stress responses, which have previously been shown to impair performance. As such, training for high-acuity events should include interventions targeting stress management skills.

The 80-hour workweek restriction: How are OB/GYN resident procedure numbers affected?

OBJECTIVE

To evaluate the surgical caseload in a military obstetrics and gynecology residency program, prior to and after implementation of an 80-hour workweek.

METHODS

A retrospective cohort study evaluating data submitted to the Accreditation Council for Graduate Medical Education (ACGME) for cumulative resident procedures in obstetrics and gynecology for the years before (July 2001-June 2002) and after (July 2002-June 2003) 80-hour workweek implementation. Total obstetric and gynecology procedures were examined using both the Student's paired t-test and a two-way mixed factor analysis of variance.

RESULTS

Between July 2001 and June 2002 there were 822 gynecological cases and 3958 deliveries done by 17 OB/GYN residents; these were compared with 827 cases and 3504 deliveries done by 18 OB/GYN residents between July 2002 and June 2003 (p=0.189). The total numbers of obstetric and gynecology cases pre- and post-80-hour workweek intervention were similar when evaluated by month (July through June of 2001/2 vs. 2002/3; p=0.908). There was a significantly greater number of obstetrics cases compared with gynecological cases (p < 0.001) in the pre- vs. post-80-hour workweek groups; the number of gynecological cases remained constant in the post-80-hour workweek group while the obstetric numbers dropped (p=0.001).

CONCLUSION

The 80-hour workweek restriction resulted in similar total numbers of obstetrics and gynecology cases, although the total number of obstetric cases per resident declined after implementation.

Protected educational rotations: a valuable paradigm shift in surgical internship

OBJECTIVE

The first year of surgical training sometimes includes marginally educational or service-related tasks with limited direct interactions with faculty. We instituted a prototype rotation to address the changing needs and expectations of our intern class. This study was designed to evaluate the new rotation 17 months after it was implemented.

DESIGN

Interns spend 4 weeks in our outpatient surgery center. Elements of the rotation include performance of operative cases and perioperative management of outpatients under direct faculty supervision, daily one-on-one structured teaching sessions with faculty, and call coverage twice monthly. At the conclusion of the rotation, interns make a presentation on a topic of their choosing to a teaching conference. Rotation evaluations and case and work-hour logs for the outpatient surgery rotation (OSR) were compared with those for the remaining intern rotations combined. A faculty survey of the OSR also was conducted.

RESULTS

The OSR consistently received maximum overall ratings (4 of 4), significantly higher than the average overall score for the remaining rotations (3.17, p < 0.01). Similarly, teaching by faculty, time spent in the operating room, and quality of operating room time were rated significantly higher than for the other intern rotations (p </= 0.05). Interns performed an average of 44 cases in 4 weeks of OSR, compared with an average of 94 in the remaining rotations (p < 0.001), and they worked an average of 62 hours per week (range, 49-76 hours). Of the participating faculty, 93% reported that the interaction gave them the opportunity to know the interns better at a personal level, that the sessions were beneficial and improved working relationships with interns, and that the program should continue.

CONCLUSIONS

Changing program requirements, time restrictions, public scrutiny, and increasing awareness for quality of life all obligate a paradigm shift in surgical education. Our outpatient rotation is logistically simple and rewarding both for residents and faculty.

The impact of fatigue on patient safety

Modern medicine is founded on a culture of diligent, fatigued physicians. Fatigue is not desirable; however, the task of managing fatigue in health care professionals is complex and an ideal solution has not been described. Solutions need to integrate the immediate need for continued high-quality patient care, education of trainees, and the limited supply of health and human resources. Exploration of alternate scheduling models, broadened scope of practice, and new models of care delivery in demonstration projects or formal studies should be performed before widespread implementation. Appropriate evaluations are essential if well-meaning but larger scale errors in the name of patient safety are to be avoided.

The effect of work hour restrictions on the education of orthopaedic surgery residents

In 2005 the Academic Leadership Group of the American Orthopaedic Association surveyed orthopaedic program directors, chairs, and members of the Resident Leadership Forum to gather information about the effect of the Accreditation Council for Graduate Medical Education work-hour restrictions on resident education. We compared these results with a similar survey performed 2 years ago. Ninety-four program directors and chairs and 59 senior residents responded to this survey. Overall, the respondents thought the duty hour restrictions had a negative impact on orthopaedic residency education but less so than in the previous survey. This conclusion was based on perceived negative effects on professionalism, resident operative experience, continuity of care, and increased workload for the faculty. Senior residents who worked before and after the work-hour limitations were instituted were more concerned about the negative effects than junior residents. Residents did seem more rested and content but not better prepared or necessarily more attentive. Respondents were not of the opinion resident performance had improved as measured by perceptions of performance on standardized tests. Orthopaedic departments had adapted to the work-hour limitations by scheduling night float rotations, converting in-house call to home call, and by hiring additional personnel in the form of physician extenders.

24 Hours On-Call and Acute Fatigue No Longer Worsen Resident Mood Under the 80-Hour Work Week Regulations

PURPOSE

Studies in on-call residents have shown that mood is worsened by fatigue as indicated by increased scores on measures of depression, anxiety, confusion, and anger using the Profile of Mood States (POMS). In prior sleep deprivation studies, mood has been shown to be more affected than either cognitive or motor performances. The purpose of this study was to examine the effect of the 80-hour work week regulations on resident mood in general and in a post-call period (PC).

METHODS

Institutional Review Board approval was obtained to survey the residents and publish the results. POMS is a 65-item adjective questionnaire that includes subscales for measuring tension-anxiety, anger-hostility, depression-dejection, vigor-activity, fatigue-inertia, and confusion-bewilderment, with the summation of the scales forming a total mood disturbance score. Surgical residents were tested at a 9 am didactic curriculum session (9 am has been shown to correlate with the nadir of performance). Residents were tested after nights off call (NOC) or after PC. Time asleep in the preceding 24 hours and other demographic data were also collected. Acute fatigue (AF) was defined as <4 hours sleep. The two-sample t-test and linear regression were used to assess differences between groups.

RESULTS

A total of 123 standardized POMS mood questionnaires were administered on 4 occasions to 51 surgical residents, 35 men and 16 women at levels PGY-1 through PGY-5. Overall, 33 tests (27%) were taken after PC and 90 (73%) were taken after NOC. Acute fatigue residents had a mean sleep time of 2.2 (+/-1.5) hours, whereas rested (R) residents had a mean sleep time of 6.7 (+/-2.2) hours (whether PC or NOC). No statistical differences in mean values of vigor, anger, depression, concentration, fatigue, tension, or total score were observed between PC and NOC or between AF and R residents. There was no significant relationship between acute sleep deprivation and total mood disturbance, whether PC or NOC. In linear relationships, NOC total score and hours slept had r2 = 0.01 (p = 0.44), whereas PC total score and hours slept had r2 = 0.07 (p = 0.14).

CONCLUSION

Although POMS was given 4 times, only 27% were PC, which reflects our 1 in 4 night in-house coverage. In contrast to earlier studies, resident mood, as measured by POMS, is no longer related to PC/NOC or acute fatigue. Previous studies have shown that loss of sleep was associated with declining mood. The lack of such a relationship in this study may be related to the new regulations. It has been assumed that people can adapt to chronic sleep loss but have a harder time coping with the effects of acute sleep deprivation. If, however, the new regulations have relieved chronic sleep deprivation, then a well-rested resident can periodically cope with the effects of acute sleep deprivation. Perhaps by eliminating chronic sleep debt, work hour restrictions seem to have removed the negative impact of PC seen in the prior era. Further studies should increase the number of residents studied, have numerous repeat NOC and PC pairs in same subjects, compare different services with different workloads, junior and senior residents, and in-house and at-home call schedules.

Underestimating the societal costs of impaired alertness: safety, health and productivity risks

Modern society now operates on a 24/7 global basis, with around-the-clock requirements that often ignore sleep, circadian rhythms, irregular work schedules and geographical time zones. Despite overwhelming evidence, there is gross underestimation and very little acknowledgement of the risks and costs related to sleep loss, circadian disruption, sleep disorders, reduced alertness and performance. Understanding the specific factors that impede our progress in addressing impaired alertness as an important societal issue could lead to raised awareness of the risks and costs and subsequent implementation of change. Effecting change requires an understanding of the complexity of the issue and a multidimensional approach. Real world data and outcomes are required to determine the exact extent of the health and safety risks related to impaired alertness. More public awareness of the potential hazards of impaired alertness is needed among the general population to increase societal knowledge and appreciation. Physicians need to be educated about the importance of detecting impaired alertness in their patients and should be aware of the range of actions needed to help these individuals so that they do not cause harm to themselves or others. A comprehensive approach using scientifically based alertness management principles and practices offers society an opportunity to operate 24/7 while reducing the risks and costs associated with impaired alertness.

Quantification of Surgical Resident Stress “On Call”

BACKGROUND

We hypothesized that surgical resident stress involves both psychologic and physiologic components that manifest as changes in heart rate (HR) and circulating white blood cell (WBC) count. The purposes of this series of experiments were to monitor HR as a measure of stress "on call"; to monitor WBC count (1,000 cells/microL) during "on call" periods as a measure of stress; and to relate maximum HR and WBC count "on call" to surgical resident training level.

STUDY DESIGN

HR was continuously documented by Holter monitor for 24hours "on call" in interns (n = 6), junior residents (n = 5), and senior residents (n = 5). Interns (n = 4), junior residents (n = 4), and senior residents (n = 4) during periods devoid of clinical responsibilities served as controls. WBC counts were obtained from residents "off" and "on call" for interns (n = 5) and junior residents (n = 5).

RESULTS

Mean HR "on call" increased in all resident groups as compared with controls: intern mean HR increased from 71 +/- 3 to 87 +/- 2 beats per minute (bpm) (p = 0.003), junior resident mean HR increased from 74 +/- 3 to 88 +/- 4 bpm (p = 0.03), and senior resident mean HR increased from 69 +/- 2 to 80 +/- 2 bpm (p = 0.004). Intern maximum control HR was 119 +/- 3 and increased to 149 +/- 6 bpm (p = 0.005). The increase in maximum HR (control versus "on call") did not reach significance in junior residents (123 +/- 5 to 136 +/- 6 bpm, p = 0.14) and senior residents (115 +/- 6 to 116 +/- 3 bpm, p = 0.9). WBC count in interns increased from control values of 5.2 +/- 0.6 x 1,000 cells/microL to 7.5 +/- 0.9 x 1,000 cells/microL"on call" (p = 0.005). The WBC change in juniors was not significant (control: 6.8 +/- 0.7 x 1,000 cells/microL, "on call": 7.1 +/- 0.7 x 1,000 cells/microL; p = 0.37).

CONCLUSIONS

When heart rate is used as an indicator of combined physiologic and psychologic stress, surgical residents achieve stress levels of tachycardia "on call." Surgical residents also exhibit an increase in circulating WBC count "on call." Both the degree of tachycardia and the increase in WBC count are inversely related to the level of training. Senior residents cope better with stress "on call" than junior residents and interns.

Impact of Work-Hour Restrictions on Residents’ Operative Volume on a Subspecialty Surgical Service

BACKGROUND

Whether the 80 hours per week limit on surgical residents' work hours has reduced the number or variety of cases performed by residents is unknown.

STUDY DESIGN

We quantified residents' operative experience, by case category, on a pediatric surgical service. The number of senior and junior residents' cases were compared between residents from the year before (n = 47) and after (n = 44) the 80-hour limit. Residents also completed a questionnaire about their operative and educational experience. As an additional dimension of the educational experience, resident participation in clinic was assessed. Student's t-test was used.

RESULTS

Total number of cases performed either by senior (before, 1.58 +/- 0.42 versus after, 1.84 +/- 0.82 cases/day) or junior (before, 0.70 +/- 0.21 versus after, 0.71 +/- 0.15) residents has not changed (p = NS). Senior residents' vascular access and endoscopy rate increased; other categories remained stable. Residents' perception of their experience was unchanged. But residents' participation in outpatient clinic was significantly decreased (before, 66.0% +/- 14.7% versus after, 17.0% +/- 19.9% of clinics covered, p < 0.005).

CONCLUSIONS

The 80-hour limit has had minimal impact on residents' operative experience, in case number and variety, and residents' perceptions of their educational experience. Residents' reduction in duty hours may have been achieved at the expense of outpatient clinic experiences.

Factors affecting resident performance: development of a theoretical model and a focused literature review

PURPOSE

The clinical performances of physicians have come under scrutiny as greater public attention is paid to the quality of health care. However, determinants of physician performance have not been well elucidated. The authors sought to develop a theoretical model of physician performance, and explored the literature about factors affecting resident performance.

METHOD

Using expert consensus panel, in 2002-03 the authors developed a hypothesis-generating model of resident performance. The developed model had three input factors (individual resident factors, health care infrastructure, and medical education infrastructure), intermediate process measures (knowledge, skills, attitudes, habits), and final health outcomes (affecting patient, community and population). The authors used factors from the model to focus a PubMed search (1967-2002) for all original articles related to the factors of individual resident performance.

RESULTS

The authors found 52 original studies that examined factors of an individual resident's performance. They describe each study's measurement instrument, study design, major findings, and limitations. Studies were categorized into five domains: learning styles/personality, social/financial factors, practice preferences, personal health, and response to job environment. Few studies examined intermediate or final performance outcomes. Most were single-institution, cross-sectional, and survey-based studies.

CONCLUSIONS

Attempting to understand resident performance without understanding factors that influence performance is analogous to examining patient adherence to medication regimens without understanding the individual patient and his or her environment. Based on a systematic review of the literature, the authors found few discrete associations between the factors of individual resident and the resident's actual job performance. Additionally, they identify and discuss major gaps in the educational literature.

Balancing continuity of care with residents' limited work hours: defining the implications

The impact of the new resident work-hours rules on all aspects of patient care and education must be considered. While physician fatigue has taken center stage as the primary motivation behind this movement, the effect of these rules on the continuity of care for hospitalized patients needs to be critically analyzed from the perspectives of patients, physicians, and the health care system. The authors describe a conceptual framework that places continuity at the center and then considers the benefits and drawbacks of preserving continuity from the perspectives of the major stakeholders. They describe the categories of outcomes related to residents' fatigue and sleep deprivation that have been studied. Only a few studies have addressed patient outcomes, while most address resident outcomes. The authors discuss some of the possible solutions, including night float and the British system of shift work, and suggest that these solutions have different effects on each group of stakeholders, including both intended and unintended benefits and harms. Finally, the research agenda that arises from this framework is described. It includes taking into account multiple perspectives, identifying important outcomes, and considering unintended consequences. Using this framework, medical educators may better evaluate previous studies and consider remaining questions.

What do surgery residents do on their call nights?

BACKGROUND

Surgical resident education is entering a critical era of achieving core competencies despite work hour restrictions. An assessment of on-call activity is needed to maximize educational merit.

METHODS

A time-motion study of resident on-call activity was performed at a university medical center and an urban affiliate hospital. Residents were followed by "shadow" residents who concurrently recorded resident activity.

RESULTS

Activities of daily living and patient evaluation comprised the majority of on-call activity. Residents slept a median of 200 minutes per night. Cross-coverage activities accounted for 41% of pages and 19% of patient evaluation. Direct patient contact comprised only 7% of call night duties. Communication activity occupied 15% of total minutes, and a mean of 16 pages were received nightly. Significant differences in activities existed between resident levels and hospitals.

CONCLUSIONS

Call activity consists primarily of activities of daily living, patient evaluation, and communication. Sleep accounts for nearly one third of all on-call activity. These data may be useful in improving both patient care and resident call experience.

Resident Work Hours: Can We Meet the ACGME Requirements?

The Accreditation Council for Graduate Medical Education (ACGME) requires all programs to limit resident work hours to 80 hours per week with some programs allotted an extra 10 per cent for specific educational purposes. The purpose of this study was to evaluate data reflecting changes in resident schedules made in 2002–2003 to be compliant with ACGME requirements without compromising patient care or resident education. Surgery residents originally completed a work-hour survey in May 2002. The survey contained 14 daily time sheets. Residents were asked to document how their time was spent between 14 different categories delineating in-house and out-of-house hours. Changes were made to resident schedules in order to become compliant with the new regulations. After making changes in the schedule, two more surveys were completed and evaluated, once in May 2003 and again in November 2003. Final analyses compared results from May 2002 to November 2003. Surveys were distributed to 30 residents in May 2002. Twenty-two residents completed the survey with 16 surveys eligible for analysis following exclusion of abnormal rotations (i.e., research and vacation). Eighty-eight per cent of junior residents (PGY 1, 2, and 3), 50 per cent of senior residents (PGY 4–5), and 33 per cent of chief residents (PGY 6) worked more than 88 hours per week. In November 2003, surveys were sent to 32 residents. Twenty-four residents who were on our normal call schedule completed the survey. Fourteen per cent of junior residents, 33 per cent of senior residents, and 0 per cent of chief residents worked more than 88 hours per week. By making the changes described, we have substantially reduced the number of resident work-hours while maintaining our academic and patient care missions.

Resident duty hours in American neurosurgery

The unexpected death of Libby Zion, at New York Hospital in 1984, led to a series of investigations that recently resulted in profound changes in resident duty hours. On July 1, 2003, the Accreditation Council for Graduate Medical Education (the governing body of all residency programs in the United States) mandated the following work hours rules: no more than 80 hours per week, no more than 24 hours of continuous patient care (with an added 6-hour transition period), 1 day in 7 free of patient care responsibilities, and a minimum of 10 rest hours between duty periods. These rules are based on a considerable body of scientific study indicating that sleep loss affects cognitive performance and, possibly, patient care. The new work hours have stimulated vigorous debate, both pro and con. Those arguments are reviewed.

Stress and coping among orthopaedic surgery residents and faculty

BACKGROUND

Evaluations of physicians and residents have revealed concerning levels of psychosocial dysfunction. The purposes of this study were to determine the quality of life of orthopaedic residents and faculty and to identify the risk factors for decompensation.

METHODS

Twenty-one orthopaedic residents and twenty-five full-time orthopaedic faculty completed a 102-question voluntary, anonymous survey. The survey consisted of three validated instruments, i.e., the Maslach Burnout Inventory, the General Health Questionnaire-12, and the Revised Dyadic Adjustment Scale; and three novel question sets addressing background and demographic information, stress reaction and management, and the balance between work and home life. Descriptive statistics, pairwise correlations, simple t tests, and Pearson and nonparametric Spearman correlations were calculated. The simple correlation coefficient was used to assess bivariate relationships.

RESULTS

The mean overall quality-of-life score, on a scale of 0 to 4 points, was 2.5 points for residents compared with 3.6 points for faculty members. Residents reported considerable burnout, showing a high level of emotional exhaustion and depersonalization and an average level of personal achievement, whereas faculty reported minimal burnout, showing a low level of emotional exhaustion (p < 0.0003), an average level of depersonalization (p < 0.0001), and a high level of personal achievement (p < 0.0001). Only two of twenty-five faculty members (compared with seven of twenty-one residents) scored over 4 points on the General Health Questionnaire-12, indicating significant symptomatology (p < 0.01). The majority of subjects reported that a partner or spouse showed nondistressed levels of marital adjustment and satisfaction. All residents and nine of the twenty-five faculty members had mentors but judged the resource to be minimally beneficial. Resident burnout and psychiatric morbidity correlated with weekly work hours; conflict between the commitments of work and home life; discord with faculty, nursing staff, and senior residents; debt load; and work-related stress. Protective factors included being a parent, spending time with a spouse, having a physician father, and deriving satisfaction from discussing concerns with colleagues, friends, and family.

CONCLUSIONS

In pursuit of our goal of determining the quality of life of orthopaedic residents and faculty, we identified a large disparity between the two groups. The resident group reported much greater levels of dysfunction particularly with regard to burnout and psychiatric morbidity. Furthermore, with regard to our second goal; our data revealed a number of risk factors for resident decompensation, most notably, increased workload, high debt levels, and discord with superiors. In addition, our research revealed that the current support interventions by the residency program, including mentoring and facilitation of spousal adjustment, are viewed as being of little help.

Musculoskeletal problems of the neck, shoulder, and back and functional consequences in nurses

BACKGROUND

Though musculoskeletal disorders (MSDs) are highly prevalent among registered nurses (RNs), little is known about functional consequences of MSDs in nurses.

METHODS

Data on neck, shoulder, and back MSD problems were analyzed in 1,163 working nurses (response rate = 74%). Cases had relevant symptoms lasting at least 1 week or occurring at least monthly in the past year, with at least moderate pain intensity, on average. MSD problems with a frequency, duration, or pain intensity below the level needed to meet the case definition were defined as MSD symptoms. Those who did not meet symptom or case criteria at any body site were defined as asymptomatic. Odds of consequences (e.g., saw a doctor/provider, missed work, reduced/modified work, non-work activities, or recreation, medication use, inadequate sleep) were estimated for cases versus those with symptoms.

RESULTS

We found 45.8, 35.1, and 47.0% of nurses had neck, shoulder, or back MSD problems (either at the case or symptom level), respectively, within the past year. Cases were far more likely to have seen a provider versus those with symptoms (adjusted odds ratio, aOR Neck: 4.33, 95% CI: 2.85-6.56; aOR Shoulder: 4.83, 95% CI: 3.00-7.77; aOR Back: 3.69, 95% CI: 2.47-5.49). Cases also were more likely to experience all other functional consequences.

CONCLUSIONS

MSD consequences are substantial and suggest opportunities for intervention. Future research will examine the impact of work organization and physical demands on MSDs.

Sleep loss and fatigue in medical training

The effects of sleep loss and fatigue in the context of medical training is a topic that has generated considerable interest, as well as controversy, over the past two decades. The sleep deprived state in medical trainees potentially impacts on a variety of domains relevant to medical care, including performance on neurobehavioral and work-related tasks, mood and affect, learning, risk for and commission of medical errors, and the health and well-being of medical students and residents. The following review provides a summary of research conducted on this topic in the past decade, including the relation of sleep loss and fatigue to medical errors and the quality of patient care. Those few studies that have analyzed the use of operational alertness management strategies, countermeasures, and educational interventions to address and mitigate the effects of sleep loss and fatigue are also reviewed. There is clearly a need for additional research to further explore the complex interaction between sleep and fatigue and medical care, and to support the development and implementation of regulatory policies based on sound science.