2013 APDS Spring MeetingThe Effect of the 16-hour Intern Workday Restriction on Surgical Residents' In-hospital Activities
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
References (9)
- et al.
Limiting PGY1 residents to 16 hours of duty: review and report of a workshop
J Surg Educ
(2012) - et al.
The new recommendations on duty hours from the ACGME Task Force
N Engl J Med
(2010) - Accreditation Council for Graduate Medical Education. Common program requirements....
- et al.
Effect of reducing interns' work hours on serous medical errors in intensive care units
N Engl J Med
(2004)
Cited by (21)
Perceptions and Guiding Strategies to Regulate Entrusted Autonomy of Residents in the Operating Room: A Systematic Literature Review
2024, Journal of Surgical EducationPlaying the Surgical Technologist Role by Surgery Residents Improves Their Technical and Nontechnical Skills
2019, Journal of Surgical ResearchCitation Excerpt :Junior residents are faced with a reduced exposure to the operating room (OR)1,2 due to a multitude of factors that include work hours restrictions3 and operative case distributions that favor the senior residents.1 Restricting surgical intern work hours, for example, has resulted in junior residents spending more time rounding on patients and less time participating in didactic conferences, whereas senior residents spend more time in the OR.4 Faced with this challenge, surgical educators have used different outside of the OR supplemental methods to teach junior residents technical and nontechnical skills.
Keeping Residents in the Dark: Do Night-Float Rotations Provide a Valuable Educational Experience?
2017, Journal of Surgical EducationCitation Excerpt :In one study by Kahn et al.,5 residents felt that the presence of APPs during an ICU rotation had a positive or neutral effect on their education. Clearly, they have the potential to fill a patient-care need while allowing residents more opportunity to participate in direct patient care and operations.3 Studies have demonstrated an increasing amount of time is being spent on service-oriented tasks, keeping surgical residents from the operating room.
Perioperative feedback in surgical training: A systematic review
2017, American Journal of SurgeryCitation Excerpt :One major change is the implementation of work-hour restrictions.3 Although the reported effect of this change on operative case volume has been variable,4–7 there is concern that trainees do not have sufficient exposure to many standard general surgery procedures by the end of their residency training and are no longer provided opportunities for graduated responsibility that leads to autonomy.8–10 While ultimately these concerns must be addressed on a greater scale, there are nonetheless steps that individual residency programs can take to optimize the learning experience for trainees.
Comparison of Canadian and Swiss Surgical Training Curricula: Moving on Toward Competency-Based Surgical Education
2017, Journal of Surgical EducationAn Analysis of Operative Experiences of Junior General Surgical Residents and Correlation With the SCORE Curriculum
2016, Journal of Surgical EducationCitation Excerpt :In contrast, a study by Dennis et al. found that surgical interns spent less time placing central lines and more time on rounds following the 16-hour workday restriction implemented in 2012. However, there was no change in total time spent in the operating room, clinic, or performing bedside procedures.9 We identified several limitations to our study.