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Operative Experience in an Orthopaedic Surgery Residency Program: The Effect of Work-Hour Restrictions
Michael A. Baskies, MD1; David E. Ruchelsman, MD2; Craig M. Capeci, MD2; Joseph D. Zuckerman, MD2; Kenneth A. Egol, MD2
1 Orthopaedic Surgery Hand Service, Massachusetts General Hospital, 55 Fruit Street, YAW 2100, Boston, MA 02114. E-mail address: baskiesm@hotmail.com
2 Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003. E-mail address for D.E. Ruchelsman: der231@med.nyu.edu. E-mail address for C.M. Capeci: cmc352@med.nyu.edu. E-mail address for J.D. Zuckerman: Joseph.Zuckerman@nyumc.org. E-mail address for K.A. Egol: egolk01@nyumc.org
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Apr 01;90(4):924-927. doi: 10.2106/JBJS.G.00918
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Abstract

Background: The implementation of Section 405 of the New York State Public Health Code and the adoption of similar policies by the Accreditation Council for Graduate Medical Education in 2002 restricted resident work hours to eighty hours per week. The effect of these policies on operative volume in an orthopaedic surgery residency training program is a topic of concern. The purpose of this study was to evaluate the effect of the work-hour restrictions on the operative experiences of residents in a large university-based orthopaedic surgery residency training program in an urban setting.

Methods: We analyzed the operative logs of 109 consecutive orthopaedic surgery residents (postgraduate years 2 through 5) from 2000 through 2006, representing a consecutive interval of years before and after the adoption of the work-hour restrictions.

Results: Following the implementation of the new work-hour policies, there was no significant difference in the operative volume for postgraduate year-2, 3, or 4 residents. However, the average operative volume for a postgraduate year-5 resident increased from 274.8 to 348.4 cases (p = 0.001). In addition, on analysis of all residents as two cohorts (before 2002 and after 2002), the operative volume for residents increased by an average of 46.6 cases per year (p = 0.02).

Conclusions: On the basis of the findings of this study, concerns over the potential adverse effects of the resident work-hour polices on operative volume for orthopaedic surgery residents appear to be unfounded.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Kenneth A, Egol
    Posted on July 21, 2008
    Dr. Egol et al. respond to Drs. Melton and Goodwin
    NYU Hospital for Joint Diseases

    We would like to thank Drs. Melton and Goodwin for their letter in response to our recent article and for the interesting data they provided from the UK system. We can appreciate their concern about the ramifications that the work-hour restrictions mandated by the European Working Time Directive have had, and will continue to have on the training of UK orthopaedic surgical trainees.

    We agree that both in the American and English systems, the rigid regulation of trainees work-hours has been a major impetus for residency program directors to identify novel ways to maximize the efficiency and effectiveness of resident training in the office and in the operating theater during the allowable work-hours. We applaud the authors for having been able to maintain operative case loads for their trainees through modifications in their training system despite the enforced 56-hour work limit.

    The American and English systems remain distinct with regard to overall duration and work-hour restrictions. Under the current ACGME work- hour guidelines (i.e., restriction of the hours worked by residents to eighty hours per week with a maximum of twenty-four hours in one shift; all work shifts require a separation of at least ten hours; and, each resident is required to have at least one twenty-four-hour period of "non- working" time per week), our trainees complete a five-year clinical orthopaedic training program, and most graduates from our program pursue an additional fellowship year of subspecialty clinical training. Additionally, unsupervised operating lists are not part of our training system.

    It is difficult to estimate the impact that further reductions in allowable work-hours will have on American trainees. For example, within a 56-hour work limit system, an additional 24 hours of training time would be sacrificed each week on average during each year of residency training. Should additional legislation be adopted that reduces further allowable work-hours, American programs may be forced to face the same question UK programs are currently facing concerning extending the length of training.

    Michael A. Baskies, MD David E. Ruchelsman, MD Craig M. Capeci, MD Joseph D. Zuckerman, MD Kenneth A. Egol, MD

    Joel TK Melton
    Posted on June 26, 2008
    Orthopaedic training exposure can be maintained despite falling hours.
    Royal Bournemouth Hospital, UK

    To The Editor:

    We enjoyed reading the recently published article regarding operative experience and working time restrictions in an orthopaedic surgery residency program(1). Many of the issues discussed have been a topic of great debate in Europe for some years. Training in the United Kingdom has been affected by the phased introduction of the European Working Time Directive (2). Training hours have been required to come down from over 100 hours per week and currently set a 56 hour maximum. In August 2009, the limit will come down to 48 hours. These changes have been strongly resisted by orthopaedic surgeons and trainees. We are, however, confined to working within European law, enforced by the Department of Health of UK government.

    These changes have affected training but by changing working practices and maximising training opportunities, high quality training and adequate operative case numbers can be achieved. Unsupervised operating lists have been reduced in number increasing the proportion of training lists where a trainee is directly supervised by his or her trainer. Work rotas have been designed to reduce the number of trainees required to work in evening and night time hours enabling a greater percentage of work hours to fall in the day-time where senior surgeons and training are more likely to be available. Allied health care professionals have been trained and appointed to take on some of the non-essential workload traditionally performed by the orthopaedic registrars allowing the trainee to spend more time in the clinic or in the operating theatre. The length of training programs is currently under review but at present most registrars will have spent one year as a postgraduate house officer, between two and four years as a senior house officer in surgical specialties including orthopaedics, many will have spent an additional year as a junior registrar before appointment to a six year orthopaedic registrar training program. It may be that further reductions in working hours lead to additional years of training as implicated by an 8 year specialty specific training for orthopaedics which is the current plan for trainees starting their training program.

    A recent analysis of UK wide training has shown an average of 312 operative cases per year(3). This represents almost 1900 cases in training. There is some inter-program difference in operative experience and in the Wessex region a trainee sample showed that they performed on average 401 cases per year before the reduction of hours and 332 cases in 12 months after the 56 hour limit was imposed.

    Decreased working hours seem to be inevitable for trainee surgeons in all specialties but with careful workforce planning, working pattern changes and maximising training opportunities, it does seem possible to maintain adequate training exposure and operative numbers.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References:

    1. Baskies MA, Ruchelsman DE, Capeci CM, Zuckerman JD, Egol KA. Operative experience in an orthopaedic surgery residency program: the effect of work-hour restrictions. J Bone Joint Surg Am. 2008;90:924-927.

    2. The Working Time Regulations 1998, ISBN 0 11 079410 9.

    3. Insights into trauma and orthopaedic training from the ‘elogbook’. Syed TA, Lamb A, Reed M, Sher S, Freudman M, Marx C, Wallace A. Education section of British Orthopaedic Association Website.

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