Dr. Keith D. Lillemoe (Indianapolis, Indiana): This presentation is one of the ever-increasing numbers of papers designed to address the impact of the ACGME work-hour restrictions on various aspects of surgical training and surgical outcomes. I congratulate the authors for having the insight to plan this study so that they would have a true control group from the pre-work-hour restriction time period and then waiting a full year for the effects of these restrictions to mature. In my opinion, this is the most comprehensive evaluation of work-hour changes with the most complete and varied measurements yet published. It is a classic. The full results could not be completely presented in this 10-minute time limit, so I urge all of you to read it when it is published in the next few months.
The only limitation I see is that it is limited to one single institution, and again, in my opinion, that hospital and that training program is one of the finest in the world. Therefore, I wonder if the results can actually be translated to all programs around the country.
The results are somewhat predictable and reassuring. Resident burnout is diminished, they have a better quality of life, get more sleep, have a lighter workload, and increased motivation to work. All this is with no measurable statistically significant effect on patient care, based on NSQIP data, case volumes, or ABSITE scores. Not surprisingly, surgical faculty are less impressed and feel care is somewhat worse and might be much worse without the increase in their own efforts. Although I think we would all applaud the decrease in time spent in meetings or in administration that the faculty noted in response to these changes.
I think it is a great study. But I do have a few questions concerning the methodology.
The first is the response rate to your study. Today you gave the response rate of about 61%, but in the manuscript, you document that the initial survey response was about 37% and 40% in the two groups, whereas in the follow-up surveys they were 77% or 83%, over double the response rate. This suggests to me that perhaps we are mixing a little bit of apples and oranges in the interpretation and the results. Can you comment how the doubling of the response rate in the post-80-hour workweek time period may have affected your results?
Secondly, I appreciate that the NSQIP data showed no difference in overall complications or mortality. But as Dr. Warshaw said, this is somewhat a blunted analysis. Perhaps there may be more subtle findings that may show a breakdown in the communication with increased need for sign-out or expanded cross coverage. Was there an increase in sentinel events or near misses? Has the length of stay or hospital costs increased because of the perceived decrease in efficiency of the surgical interns?
Then, how did you deal with the data for comparison in the attitudes, the ABSITE scores, with respect to various resident years? By that, I mean did you compare before and after groups from the same year with each other, or did you compare the pre-interns with the post-interns in your analysis? This again, that may have altered your statistical comparisons.
Finally, a couple of philosophical questions. First, since concern exists for the interns as being a greatest risk, are you and Dr. Ferguson planning any intervention to change your training program to help avoid future problems? Secondly, clearly you demonstrated “so far so good” with respect to the effects of the work-hour restrictions. But can we be so confident that this will be the same in 3 to 5 years when the current intern class who are considered to have worse technical skill, clinical judgment, sense of responsibility and efficiency, are the residents who are going to be the key players in patient care and those residents who grew up in the old system are long gone? I assume that you are going to repeat this study in a few years time to see what kind of effects have taken place.
Finally, just a compliment I would like to pay to Dr. Hutter and his group in the Center for Clinical Effectiveness in Surgery. With both this study and your excellent paper yesterday, you have clearly raised the bar in terms of clinical outcomes research.
Dr. Matthew M. Hutter (Boston, Massachusetts): Dr. Lillemoe, thank you very much for your kind comments, and I would like to address your questions.
Yes, this is a single institution study and as such it is not necessarily generalizable to all hospitals. The fact that it is a single institution study is probably one of its greatest strengths, as well as one of its greatest weaknesses. The strength is that it allowed us to really delve into the issue, and not just scratch the surface. We were able to approach this topic from many different angles: we used timecards, we used web-based surveys incorporating validated instruments, we used quantitative information where available and had a Ph.D. investigator perform focused, structured interviews. This intensity could not be replicated in a multi-institution study. Although we think that our experience as presented in this study is probably reiterated across the country at other hospitals, the generalizability of this study is potentially a significant limitation.
Another question was about the response rate. The response rate overall was 61%. The response rate did not double over the course of the study, however the response rate for the timecards decreased, while that for the web-based survey increased from one year to the next. I am sorry if that was not clear.
You also asked about other issues—sentinel events, length of stay or other metrics one could look at. We did look at many of these issues. There was no change in sentinel events from before to after the work hour changes. Length of stay has gone down, although it is hard to attribute that specifically to the 80-hour workweek changes. It is more likely to be able to be attributed to the increased use of clinical pathways, which have lead to a dramatic decrease in length of stay—particularly our bowel surgery pathway.
Next you had a methodological question with regards to how we analyzed the groups. We did do analysis by postgraduate year. PGY 1s were compared to the PGY 1s for the next year, and the same with PGY 2s, 3s etc. We did not compare responses by an individual per se as they progressed along their training.
In answer to the philosophical questions that you had, yes, we did identify that the interns were the group that seemed to be most affected by the work hour changes. And yes, we are quite concerned about what this might mean when today's interns are tomorrow's seniors. What have we done about this? Well first of all, we put the interns back on call with “their” seniors. When we first instituted these changes we had split up call so that the intern was no longer taking call so that the intern was no longer taking call with the senior on their team. An important mentoring relationship was lost with these changes, so we changed it back. We have also developed a skills lab, as well as a skills curriculum to help remedy this situation. We have developed a night float systems, so that the interns would be around during the day in order to participate in the care of the patients, and not just put out fires at night. We have hired more nurse practitioners. We have a long way to go, but these are some of the things that we have started to do already to improve the education of the interns.
The loaded question that you put forth is, “where will we stand in three to five years”? Only time will tell.
The ACGME work hour restrictions are here to stay. And I applaud the ACGME in doing this. If they didn't do it, then some other government mandated program would be making us do it. Work hour changes are not going away, and we need to deal with that, stop whining, and make the most if it.
One aspect that we really need to change is our attitude. The residents have been forced into this 80-hour workweek—they did not necessarily choose it. As attending surgeons, it is never productive to say that, because of these changes, the residents are not going to be good surgeons. They are surgical residents because they want to be good surgeons, and it is extremely harmful and counterproductive for them to hear that they may never live up to this because they didn't do it “the old way.”
Dr. Timothy C. Flynn (Gainesville, Florida): I do commend this, like Dr. Lillemoe did, to the membership because it is a piece of work that is probably not ever going to be repeated. It has been 2 and a half years since the ACGME established limitations on resident duty hours, and the GME community as a whole is just beginning to understand the impact of these rules on resident education in the teaching hospitals' processes of care. This paper, as unique as it is, is one that will make a significant contribution to that understanding. And while the response rates for some areas studied were not high, I really don't think this in any way diminishes the value of your report, and it may help us provide information to manage the complex systems that are at teaching hospitals.
As you all know, this topic is of no small interest. There have been papers on the impact of the ACGME rules at virtually every major surgical meeting that I have attended over the last 2 years.
A recent meta-analysis in Sleep, published this month, reviewed 60 papers on the effect of sleep loss on physicians, and implied that the current rules allow for situations where sleep loss can be detrimental and degrade performance. An editorial suggested that the current rules endangered patients by exposing them to physicians who work 24-hour shifts.
In reviewing the literature on duty hours, it is interesting to compare the reports that are written by surgeons and non-surgeons on these issues. Surgeons tend to focus on many of the issues that you discussed, the negative effects on continuity of care, the purported developing shift work mentality, and the risk of repeated hand-offs. Non-surgeons typically are impressed with the experimental data that show declines in cognitive function, negative effects on the individual physician of prolonged sleeplessness.
We should keep in mind where these rules came about. In my opinion, the major stimulus was the IOM report “to err is human,” which suggests that hospital care is hazardous to your health. And I think there is no small number of things that we are seeing that are reaping the whirlwind of this report, including the “pay for performance” activities that we are all going to have to live under.
So what does it all mean? First, as you say, we are never going back to the “good old days.” Second, we have got to figure out how to make this system work to produce the type of surgical practitioners we would like to take care of us. This paper offers some hopes and many challenges. I am encouraged by your observation that burnout motivation scores were improved. Other studies have shown that we take otherwise enthusiastic and idealistic interns and make them bitter and disillusioned by about September of that intern year.
My first question is this: How can we use this improved sense of self-value to create a surgeon well-grounded in the values and social context of caring? Could you not capitalize on this to address the issues of your concern about the reputed decline in dedication to patient care and professionalism?
You noted no change in the NSQIP data. And as noted, this was a relatively blunt instrument and can be interpreted two ways. Limiting the duty hours has not contributed positively to safety, one of the stated goals of the reduction of duty hours. On the other hand, you could say, well, it really hasn't hurt it. And as you note in your paper, you suggest that the faculty are picking up the slack. How do you put this in context with your observations?
Lastly, you devoted a good deal of time in your paper to the interviews of faculty and residents. One of the things that really struck me was the difference in perception of the current situation between the residents and the faculty. The faculty, before the rules went into, as noted, thought that the changes would be somewhat worse. And sure enough, after the rules were put into effect, things were described as somewhat worse. Residents, especially junior residents, seemed to be much more positive. As one resident said, “I think that it has helped me to, like, truly enjoy life as a whole.” You can tell this is a member of the new generation by the gratuitous use of the word “like,” which seems to be every fourth word for my children.
The general thrust of the faculty comments are that the intern class is less dedicated to patient care and quality of work. I would submit that this is an unfair criticism of this group of individuals. There is no doubt that the current group of medical school graduates is different. In this context, I take some exception to your including in your paper a quote by a faculty member about the intern class “now they are entitled to work less, to be less tough, now they are softies.” And while that may be a quote from any number of people, perhaps some in this room, this attitude is not going to be perceived positively by this generation of medical students.
What makes you think that the concerns you expressed are a reflection of the duty hours themselves and not just an older generation looking back romantically on “the good old days” and of the generational difference that we know exists? Are not many of the faculty concerns more about how residents function as providers of patient care and less about their education?
The difficulty we as surgeons are having in no small part is a service versus education problem in our complex systems. In my opinion, our job is to educate healthy, positive, competent physicians. We need to get over the fact that the ground rules have changed and get on with the tasks. You have identified several areas of concerns, issues that people all over the country are talking about. We need to use our considerable talent to solve it.
Dr. Matthew M. Hutter (Boston, Massachusetts): We don't know what the future is going to hold. We are here to provide some information—a snapshot—of what things look like at one point before the work hour changes and what things look like a year later. What we found does raise a lot of questions—questions that I don't think we will have answers to for quite some time. I don't think I will be able to answer all of your questions right now.
One of the overriding questions that you were referring to was the concept of service versus education. At our institution, the work hour restrictions allowed us to take a step back and look at each aspect of each rotation in our residency and ask, “Is this worthwhile for their education or not?” It forced us to look objectively, to separate the wheat from the chaff, and the resultant changes in the residency rotations were for the better. Oour goal was to cut out the scut—the service aspect of the rotations—while preserving the educational components. This introspection was a very positive aspect of the ACGME mandated work hour changes.
We were also able to preserve case volume, as shown in our study. But case volume is not what makes a doctor. Now we need to go back and think about how are we are going to create a doctor, to create a compassionate healer as opposed to a technician. And a lot of that will come through continuity of care, from following a patient through all aspects of their illness and recovery. Continuity of care does not necessarily mean being in the hospital 120 hours a week, which is how we provided continuity of care before. A new paradigm for resident education will need to be developed. We see in this study a move away from a patient focused culture to a shift worker mentality. Residents probably lean more from experiencing the continuum of a patient's care—watching a patient as they present, are diagnosed, as they undergo an operation, and how they do in the postoperative setting. This is very hard to incorporate into the system we have now, however this is something that we need to do.
You took exception to the quote from an attending interview that was in the manuscript that “the new interns are entitled to work less, to be less tough, now they are softies.” This is the attitude that a lot of people have. I personally do not think that this attitude is constructive. The residents want to be good doctors. And we need to help them be good doctors. By telling them they are never going to be any good is absurd. You would never say that to your own child. The residents are our children and we want to see them grow and develop. I present that as a fact, as an attitutde that some have, but I don't necessarily condone the statement.
Dr. Robert T. J. Holl-Allen (West Midlands, England): May I gently criticize that the 56-hour week does not cover attendings. They have no limitation on the hours they have got to work I emphasize the word “got.”
I can speak because I am a member of a family who is involved in the new system, and it involves a lot of shift work, where they work so many hours per day or per night. And this has led to a lot of problems, particularly with handover, continuity of care, but above all, the training of surgeons.
It has reached, I think, a crisis level. Because our president was on national television only a week or so ago indicating that if the week stayed as it was the 56 hours or it went down as we are anticipating in 2 years time to 48 hours, the training of surgeons was now being compromised very severely. And we do not have the luxury of simulators in every hospital. We have very few.
And this has been recognized by my son, who is a courtroom attorney, and myself, both involved in medicolegal work. We are being inundated. And it is quite clear that at the level that the residents are now are inadequately trained and are making major errors of decision because they are not getting the experience, what is going to happen if it goes down to 48 hours?
At the moment, there are sufficient doctors to cover most of the shifts, but the government, of course, has the control over the finances. And only on the airplane coming out did I read that a letter has been sent out by the government to ask hospitals to stop operating to save money. They cannot afford to do certain operations.
This, I think, indicates what is going to happen to surgical training with the reduction in hours. And I think you have to fight to keep your 80-hour week. It seems that the residents are getting a reasonable life, reasonably hard work and I can say I was a resident over here for a while and I think that you have got to keep that 80-hour week. You can't get any less. Because you can learn from the mistakes we are making, or being made in the United Kingdom, in terms of cutting the number of hours. And I think the training will be severely compromised the more hours that are cut.
And there is talk talking to a French surgeon friend of mine that on the continent they want to go down to 40 hours. That would be an unmitigated disaster.
Dr. Matthew M. Hutter (Boston, Massachusetts): I think that we in the US have a lot to learn from what is going on elsewhere with regards to surgeon work hours. The United Kingdom, Germany and the rest of the European community, as well as Sweden, have already adopted much more restrictive work hour changes. This work force restructuring that we have just embarked on in the US is an ethnographic experiment of a huge magnitude. The more information we have—whether from experiments and studies in our own institutions in the US, or from examining what is happening overseas—the better off we will be. 56? 48? 40 hour work weeks? Who knows what is ahead for use or for other surgeons in other countries.
Dr. Thomas F. Dodson (Atlanta, Georgia): I have no barbs and arrows for Dr. Hutter, Dr. Warshaw, Dr. Ferguson, and their colleagues. I rise to congratulate you for your excellent paper.
I think you made one really important point among other things that you have said, and it is a key thing, and I would just repeat it because the flaw that I see in this process are physicians of my age group I am 60 years old who denigrate or criticize our residents for going home at the end of their shift, at the end of their 30-hour workweek, and make them feel as if they are not living up to the standards that we set in the past. If I could change one thing in this 2 and a half days of discussion we have talked about culture change, if I could change one thing in the culture, this would be the thing I would change: I would stop nonconstructive criticism of the current generation.
I would add one note, and then I have two questions. The note is that not all is sanguine in New England, and Irani and co-authors at the Brigham in the Journal of Surgery in August of 2005, did a mailed survey to 19 New England programs, with a response rate of 36%, but they had some interesting findings: 60% of the residents reported doing fewer operations and 39% reported that the requirements had worsened the quality of their training. Although they did have some positive remarks along the way, those are two very negative findings from a mailed survey to 19 New England programs.
My two questions are these: You noted in your paper that the attendings felt the quality of life was “somewhat worse,” as well as the quality of patient care, and continuity of care. Mary Flingensmith from Washington University in St. Louis published a paper in the Journal of the American College of Surgeons in 2004 where she documented that the staff work was increasing; it was actually over 70 hours, and she hypothesized that over time the staff work would exceed that of the residents' work. I just wonder what your thoughts are on how we might improve the attendings' perception that things are really not going so well.
My second question and it is one where “the rubber meets the road” when people leave the hospital mid-day, the biggest potential problem is communicational during the hand-off. How do you hand off the service from one individual to another? How do we avoid making the errors that come when somebody doesn't know the patients as well? There have been a lot of suggestions about this: PDAs lists, so on and so forth. I would be interested in how you assure that you have no problems with communication at hand-off.
Dr. Matthew M. Hutter (Boston, Massachusetts): Dr. Dodson, I agree agree with your first comment with regards to non-constructive criticism. That is something we need to stop.
With regards to negative findings in the Irani paper—that the residents reported that the requirements had worsened the quality of their training—I think that the residents feel this way because we, the attendings, are telling them that. Again, this is not constructive and needs to stop.
You ask, “How do you change the attendings' perceptions?” Well I think you show them the data, like I have attempted to do here. The residents are coming to conference more, they are reading more, they tend to do better on the ABSITE, and they have increased motivation to work and decreased emotional exhaustion. There are many good aspects of the work hour changes and we need to highlight that.
We also need to find out what the problems are and make them better. Telling people they are doing a bad job is not constructive—it is just mean. If they are doing a bad job, it is our fault. As our program director Charlie Ferguson would say, “if they are not doing a good job, it is because we are not teaching them the right way.” That is our job—to teach them.
“Handoffs” were identified from this study as a major issue. Our follow-up work from this study focuses on handoffs. We, and others, are yet to come up with the answer of how to mitigate this most serious side effect of the work hour changes, but we are trying to find some solutions.
Dr. L. D. Britt (Norfolk, Virginia): Myself excluded, I found it interesting we have three former chairs of the RRC in the audience now (Dr. Polk, Dr. Diethelm, and Dr. Bland) and there are four others at this meeting who are on the RRC. I am sure it was an oversight that not one was invited as an invited discussant.
However, my question is this: The residents have novel ways of fudging the hours. Even New York after a few hours, a few years down the road, they had 100% noncompliance of their 80-hour workweek. How did you specifically validate that the residents were actually doing 80 hours? That is my concern. And I think studies early are too premature unless you have some fancy way of validating that the residents are actually going home.
Dr. Matthew M. Hutter (Boston, Massachusetts): I am sorry for the oversight in choosing discussants. No offense was meant.
How did we actually validate that residents were doing 80 hours? Well, we did not specifically track them with an RFID device or other surveillance technology, though that might be the only way to get an accurate assessment. We did however try to address this with a computerized information technology query that we developed. The hospital computer system is the lifeblood of the residents these days. Everything is done on the computers. Before they can access the computers, they had to fill out a questionnaire with regards to the duty hours. Those results were compared to whether they had used the computer system when they said they were not there. Whether this is accurate or not is difficult to ascertain. We also compared the results from the timecard survey to validate the computer results, and we did find concordance. Our results show that, for the most part, we have been compliant.
I have been drawn to multiple facets of medicine since beginning medical school. I have been intrigued by the intricacies of disease and the ability of physicians to alter the course of the illness. Not surprisingly choosing one discipline was challenging until the last week of my internal medicine clerkship when I was given a "gem" in the form of Maria. She was, according to my resident, the "perfect medical student patient." Without her knowing it, Maria was also responsible for my decision to become a dermatologist.
"She has a rash" was the only briefing I had as I entered Maria's room to begin my H &P, unsure what I would find with this "perfect" patient. With my limited Spanish and her limited English, our conversation was minimal but Maria was clearly in pain. The tense bullae and open, oozing areas covering her lower body made it visibly uncomfortable for her to sit. Maria gingerly touched multiple affected areas as I fumbled through my exam in Spanish asking her where she had "dolor." Tests were done, treatment started empirically. My attending provided a book for me to review on cutaneous manifestations of systemic diseases, instructing me to present to our team the next morning on common skin symptoms indicating underlying disease. I spent the rest of the day reading, fascinated by the pathology that presents itself on our bodies' surfaces. Maria clearly had more than a rash, and as I attempted to put together the pieces of her illness, the pieces of my own career path seemed to align. And as Maria improved and her pain decreased I knew I had found a field that would be fulfilling on multiple levels.
Dermatology combines the fields of medicine that captivate me most- infectious disease, immunology, and oncology. The discipline both fascinated and intimidated me in my first encounters with dermatopathology in course work and in actual dermatological pathology with patients. Skin pathologies were commonplace on my first year elective in South Africa where the combination of immunosuppression, poverty, congested living conditions, and a damp, cold winter caused our clinics to overflow with patients needing to be seen for various fungal infections, nonhealing wounds, and the multitude of infectious diseases running rampant in the townships. With treatment options limited to basic dressings and antibiotics, we did not have the advanced tools of diagnosis available in a typical American hospital. As a result, our primary concern was limited to the treatment of ongoing or prevention of secondary infection. Through the clinical clerkships of my 3rd year, I was drawn to patients with skin pathologies, spending extra hours in the burn clinic with advanced skin cancer patients, diligently checking the feet of my patient just home from Iraq whose tinea pedis infection served as a portal for staph bacteremia, and intrigued by the lacy "slapped cheek" pattern on my pediatric patient with Parvovirus B19.
The American Medical Student Association has a slogan "It takes more than medical school to make a physician." I was inspired by these words early on in my medical school career and realized this was particularly true for me as I made every effort to be involved in multiple extra-curricular activities relating to my passions in medicine. Although the core education in basic and clinical sciences is essential, it is the other activities which distinguish future physicians as unique individuals and help maintain the humanistic dimension of medicine. I will bring the same energy and passion to residency and my career that I have throughout medical school, allowing me to develop my leadership and communication skills while succeeding academically.
With the increased need for skin care in our fragile environment and the abundance of opportunities for work both locally and internationally, I am excited about the possibilities offered by dermatology. I look forward to working with patients of all ages and to being challenged intellectually throughout my career. With a background in public health and clinical research, I plan to become an active investigator in the dermatology field and contribute to advances in patient care through design of and participation in clinical trials and work actively in the community to develop primary prevention programs to decrease preventable disease. Working as part of a health care team is a high priority for me as I staunchly believe the best patient care is accomplished when collaborating with colleagues throughout the health professions. In a residency program, I hope to find a program which reinforces these values and one which promotes collegial interactions between residents and faculty in an environment where there is potential to be exposed to a wide variety of dermatological conditions.