Elsevier

Journal of Surgical Education

Volume 70, Issue 6, November–December 2013, Pages 800-805
Journal of Surgical Education

2013 APDS Spring Meeting
The Effect of the 16-hour Intern Workday Restriction on Surgical Residents' In-hospital Activities

https://doi.org/10.1016/j.jsurg.2013.02.001Get rights and content

Objective

To observe the effects of the 2011 Accreditation Council on Graduate Medical Education 16-hour intern workday restrictions on surgical residents' clinical and educational activities.

Design

All the residents recorded the following weekly in-hospital activities during February and March 2011 (year before intern work restrictions) and 2012 (first year under new requirements): operating room (OR) and clinic; bedside procedures; rounds and ward work; on-call duties in hospital; communication (e.g., checkouts and family and patient discussions); education (conferences and study); and personal (rest and meals). Descriptive statistics were calculated in 3 resident groups (interns, first postgraduate year [PGY1]; junior, PGY2 and 3; and senior, PGY4 and 5). The unpaired t test was used to compare data between 2011 and 2012; significance was set at p< 0.05.

Setting

Medical school affiliated hospital.

Participants

Categorical resident trainees in surgery, PGY1-5, 4 residents per level, with all 20 residents participating in the study.

Results

From 2011 to 2012, time spent in the hospital by the intern did not change (all results in h/wk, mean±standard deviation: 68.5±13.8 to 72.8±15.8, respectively) but the time devoted to specific activities changed significantly. In-hospital personal time decreased by 50% (5.3±4.6 to 2.6±2.0, p = 0.004). Interns spent less time placing central lines (2.1±2.2 to 0.9±1.2, p = 0.006) and more on rounds (8.8±8.8 to 14.2±9.8, p = 0.027), which included supervision with upper level residents. There was no change in the total time spent in the OR, the clinic, performing bedside procedures, and educational activities. Changes in intern work did not affect the time junior and senior residents spent on bedside procedures, time spent in the clinic, and total time spent in the hospital. In 2012, junior residents spent less time in educational activities (11.4±8.5 to 7.0±4.5, p = 0.0007) and the seniors spent more time in the OR (13.7±7.5 to 20.6±10.7, p = 0.0002).

Conclusions

The 16-hour restriction preserved interns' educational activities and time spent in the OR and clinic, but changed resident work activities at all levels. The time spent on rounds increased, time spent by the juniors on conferences decreased, and time spent by senior residents in the OR increased. Duty restrictions in general and intern supervision requirements demand ongoing adjustments in resident work schedules.

Introduction

Beginning from July 2011, the Accreditation Council for Graduate Medical Education (ACGME) required U.S. training programs to limit intern work hours to 16 hours for a given 24-hour period.1 The rationale was that the most inexperienced cohort of trainees, those in their first postgraduate year (PGY1) following completion of medical school, was most affected by sleepiness and fatigue. A corresponding requirement was that more senior residents directly supervise PGY1 resident performance. The goal of these rules was to mitigate the effects of fatigue, sleepiness, and inexperience among interns, building on the original duty-hour restrictions imposed by ACGME in 2003 on all residents.2

The intern work rules were based, in part, on the research data on the work performance of PGY1 residents in intensive care units and reviewed by Tan et al.3 Elimination of the 24-hour call shifts and limitation of scheduled hours of work to 63 per week decreased the number of serious errors made by interns on an intensive care unit rotation.4 Interns were found to be at an increased risk for a car crash immediately after an extended work shift of more than 24 hours and in the months when they worked more than 5 shifts.5

Despite scientific evidence that work restrictions decreased trainees' clinical performance and improved their well-being, concerns persisted whether a limit is being reached regarding the minimum number of hours needed for a meaningful training experience in surgery.3 A survey of internal medicine and surgery directors indicated that the new work restrictions would negatively affect both the learning environment and the patient outcomes.6 A workshop at the 2011 meeting of the Association of Program Directors in Surgery summarized some concerns, including reorganization of residents' schedules, costs associated with physician extenders to cover noneducational work, and the effects of hand-offs on continuity of care. An important issue was the effect of duty-hour restrictions on resident's learning and attending surgeon's teaching, and whether attendance at teaching conferences and rounds, and time spent in the operating room (OR) would suffer.

We wanted to determine the changes in hours spent in clinical, educational, and service activities experienced by surgical residents in training brought on by the new work restrictions on interns' workday. Accordingly, we conducted a time-work study on all residents in our residency program in surgery during the last year before the new rules took effect on July 2011 and during their first year in practice.

Section snippets

Time-Work Survey

All surgery residents completed a form that summarized their work, study, and personal activities in 15-minute intervals while in the hospital (Table 1). Surveys were taken during an 8-week period in February and March 2011, before the institution of the 16-hour intern work limitation in July 2011, and during a similar period in the same 2 months in 2012, during the first year it went into effect. Weeks when the resident was on vacation, on a rotation not on the main hospital campus, or on a

Results

All 20 residents, 4 from each PGY level, participated in the study. Time spent in various work activities changed according to resident level and by the rotation, which involved different degrees of inpatient, OR, clerical, and emergency duties. Standard deviations were therefore large, reflecting a large degree of variability within a single activity category. Still, statistically significant differences emerged.

From 2011 to 2012, there was no significant difference in the amount of time the

Discussion

Differences in work activity emerged even though a night float system was already in place, conference schedules did not change, and there were only small increases in total number of cases and admissions. Accommodation of intern work restrictions only required the elimination of the weekend 24-hour shift for interns. Therefore, most of the established work patterns remained the same, leading to the expectation that the observed times spent would not change. Still, statistically significant

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