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Ann Thorac Surg 2005;80:1569-1571
© 2005 The Society of Thoracic Surgeons

Editorial

Impact of Resident Duty Hour Standards on Cardiothoracic Residents and Program Directors

Jacob DeLaRosa, MD a , * , Vinod H. Thourani, MD b , Grason H. Wheatley, III, MD c , David Michael McMullan, MD d , Raffy L. Karamanoukian, MD e , Mary G. Greene, MD, MPH f , David L. Morales, MD g

a Division of Cardiothoracic Surgery, Idaho State University, Pocatello, Idaho
b Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
c Division of Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
d Division of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia
e Department of Surgery, University of California Irvine, Irvine, California
f CTSNet, Baltimore, Maryland
g Texas Children's Hospital, Houston, Texas

* Address correspondence to Dr DeLaRosa, Idaho State University, Portneuf Medical Center, 777 Hospital Way, Pocatello, ID 83201 (Email: idahoheart{at}aol.com).


   Introduction
Top
 Introduction
Comment
 Conclusion
 Footnotes
 References
 
In July 2003, The American Council for Graduate Medical Education (ACGME) implemented mandatory restrictions on resident duty hours for all residents enrolled in post-graduate training programs. The Resident Duty Hour Standards (RDHS) affected nearly 100,000 residents in the United States and have effectively changed the quality and quantity of resident clinical exposure over a finite training period [1]. Although much has been written regarding the effects of the RDHS on junior-level residents, there remains a paucity of literature on the impact of these work hour restrictions on residents within the subspecialty of cardiothoracic surgery. Therefore, a questionnaire was designed to assess the perceptions of cardiothoracic residents and their program directors regarding the RDHS.

More specifically cardiothoracic residents and program directors were individually surveyed regarding the direct affects of RDHS on patient care, continuity of care, clinical exposure, and the acquisition of clinical accountability and responsibility. Furthermore, the effects of RDHS on quality of life and the reduction of work-related and social stress were also evaluated.

Three hundred eighty-nine cardiothoracic residents and ninety-two cardiothoracic program directors were invited to anonymously respond to a web-based questionnaire hosted on CTSnet.org. One hundred fifty-five residents (40%) and 50 program directors (54%) participated in the study. The mean age of the residents was 35 years (range, 26 to 47 years). One hundred thirty-six males (88%) comprised the majority of residents in the study. The summarized responses of the program directors and residents to the RDHS survey are tabulated in Table 1. Residents ranked how they allocate their typical post-call day off, and program directors also ranked what they believe residents do during their time off. Both groups selected sleep as resident's number one activity during off-periods (Table 2).


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  		Table 1. Resident and Program Director Survey Results
 

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  		Table 2. Allocation of Post Call Day Off
 

   Comment
Top
 Introduction
 Comment
Conclusion
 Footnotes
 References
 
The implementation of resident work hour restrictions was an attempt by the ACGME to institute a comprehensive approach to address duty hours in all accredited residency programs in the United States. As a result, resident trainees are limited to an average of 80 hours per week with dedicated time for off-duty periods and defined limits on the frequency of on-call days. The basic principle behind these measures has been to optimize patient care and maximize the well-being of resident trainees.

Lengthy surgical cases, high clinical volume, and complex patient care issues have traditionally required thoracic surgery residents to work some of the longest hours among residents in training [2]. This makes the challenge of coming into compliance with the duty hour restrictions all the more difficult for thoracic surgery program directors. Thoracic surgery training programs are also faced with the problem of having a limited number of residents to reallocate or use to restructure responsibilities. The number of thoracic surgery residents in training is relatively small compared with other medical and surgical specialties. There are approximately 380 thoracic surgery residents spread among 90 training programs. As a result, thoracic surgery residency training is uniquely challenged because it possesses many significant obstacles against implementation of the new duty hour restrictions.

Although implementation of the RDHS has resulted in salutary effects on resident well-being as confirmed in recent studies and validated by our own study, medical educators remain concerned in regard to the direct effects of these restrictions on clinical exposure and competency [3]. Our own study demonstrated that 78% of residents believed that there was an improvement in resident well-being. Only half of the program directors agreed that resident well-being was improved. The question remains whether imposing work hour restrictions provides enough exposure for thoracic residents to acquire core competency during a finite period of time. One program director commented, "There is no sense in complaining about the 80-hour workweek because ‘it's the law'. I am concerned that in the future we will be creating more and more CT [cardiothoracic] surgeons with less and less experience or even exposure to certain operations. The residency review committee will be happy but who is going to pay for this fiasco? I don't think that what I went through when I was a resident was necessarily the right thing but the opposite extreme (aka, the 80-hour workweek) is not the right answer either; we must be allowed the flexibility to find the solution in between the two extremes." Based on recent studies, certain subspecialties have experienced a significant decrease in the absolute quantity of resident work hours. A study in Boston reported a mean workweek of 105 hours among surgical residents surveyed in the New England area [4]. In this subgroup, an 80-hour workweek would result in a 24% reduction in clinical activities; whether this equates to a perceivable drop in valuable educational time remains to be seen. Given the demand for long duty hours and patient continuity of care among cardiothoracic surgery residents, this is a subgroup that is most affected by workweek reform.

RDHS has caused an increased financial burden to hospitals and departments. Increased clinical activity by faculty has been a typical response to ensure departmental financial needs as stated by the ACGME that "the clinical role of the attending physician will expand in a system of constrained resident hours" [5]. Hospitals and programs have to hire additional ancillary help such as nurse practitioners and physician assistants to do the work previously done by residents [6]. Faculty staff also had to endure longer hours as reported by the American Medical News [7].

New paradigms in residency training are needed to address these critical issues both within cardiothoracic surgery and within graduate medical education as a whole.

In addition, future studies will need to examine whether decreased case volumes by cardiothoracic surgery residents will impact their ability to meet the residency review committee case volume requirement.

With potentially declining case volumes, the role of virtual reality simulator training for cardiothoracic surgery residents may become more important.

Virtual reality simulator models are being developed for a number of procedures and may need to become an integral component for surgical training programs in the future [8]. Most importantly, will decreased clinical exposure impact the residents' ability to be good clinicians, and safe effective cardiothoracic surgeons?


   Conclusion
Top
 Introduction
 Comment
 Conclusion
Footnotes
 References
 
In a graduate medical education system, which is time-limited, the impact of reduced residents' clinical and didactic activities will need to be assessed long term. Cardiothoracic residents, program directors, and the ACGME need to work together to establish limitations that do not hamper the specialist residency experience. Generalized resident duty hour limitations placed on residency training are not the solution to improving overall resident well-being, academic and clinical education, and balancing the needs of patient care.

Senior residents in their post graduate year 6-11 are sophisticated enough to know their limits and how to provide the best patient care without limitations being imposed by outside sources. The information gathered from these surveys will be useful in assessing compliance and determining future program changes.

Because thoracic surgery is a small residency training specialty, we have the opportunity to lead the way for all medical and surgical specialties in standardizing implementation of duty hour restrictions and developing creative solutions to this challenging issue for thoracic surgery resident education.

We must continue to study the effects of the RDHS on cardiothoracic residents, specifically the detrimental effects of the residents operative case volume and if programs are strictly adhering to the mandates by the RDHS. The program directors must also continue studying the effects to see if they are truly meeting their goals of ensuring quality patient care, providing excellent residency training, and producing well-prepared cardiothoracic surgeons.


   Footnotes
Top
 Introduction
 Comment
 Conclusion
 Footnotes
References
 
Presented at the Forty-first Annual Meeting of The Society of Thoracic Surgeons, Tampa, FL, Jan 24–26, 2005.


   References
Top
 Introduction
 Comment
 Conclusion
 Footnotes
 References
 

  1. Accreditation Council for Graduate Medical Education Report of the Work Group on Resident Duty Hours and the Learning Environment, June 11, 2002. 2004Available at http://www.acgme.org (accessed July 16.
  2. Lamber L. Long hours little sleep, bad medicine for physicians-in-training JAMA 2002;287:303-307.[Free Full Text]
  3. Goldstein MJ, Kim E, Windmann WD, Hardy MA. A 360 degrees evaluation of a night-float system for general surgerya response to mandated work-hours reduction. Curr Surg 2004;61:445-451.[Medline]
  4. Whang EE, Perez A, Ito H, Mello MM. Work hours reformperceptions and desires of contemporary surgical residents. J Am Coll Surg 2003;197:624-630.[Medline]
  5. Philibert I. A few more frequently asked questions about resident duty hours ACGME Bull 2002;14:14-15.
  6. Roebuck K. Residents: 80-hour week the best Rx. Pittsburgh Tribune Review, July 4, 2004. PittsburghLive.com..
  7. Croasdale M. Resident work-hour limits still a struggle one year into restrictions. American Medical News, July 19, 2004. Available at http://www.amaassn.org/amednews/2004/07/19/prl10719.htm..
  8. Gallagher AG, Christopher UC. Approval of virtual reality training for carotid stentingwhat this means for procedural-based medicine. JAMA 2004;292:3024-3026.[Free Full Text]



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