Special Topic Duty Hours and Home Call: The Experience of Plastic Surgery Residents and Fellows Brian C. Drolet, M.D. Adnan Prsic, M.D. Scott T. Schmidt, M.D. Providence, R.I.
Background: Although resident duty hours are strictly regulated by the Accreditation Council for Graduate Medical Education, there are fewer restrictions on at-home call for residents. To date, no studies have examined the experience of home call for plastic surgery trainees or the impact of home call on patient care and education in plastic surgery. Methods: The authors distributed an anonymous electronic survey to plastic surgery trainees at 41 accredited programs. They sought to produce a descriptive assessment of home call and to evaluate the perceived impact of home call on training and patient care. Results: A total of 214 responses were obtained (58.3 percent completion rate). Nearly all trainees reported taking home call (98.6 percent), with 66.7 percent reporting call frequency every third or fourth night. Most respondents (63.3 percent) felt that home call regulations are vague but that Council regulation (44.9 percent) and programmatic oversight (56.5 percent) are adequate. Most (91.2 percent) believe their program could not function without home call and that home call helps to avoid strict duty hour restrictions (71.5 percent). Nearly all respondents (92.3 percent) preferred home call to in-house call. Conclusions: This is the first study to examine how plastic surgery residents experience and perceive home call within the framework of Accreditation Council for Graduate Medical Education duty hour regulations. Most trainees feel the impact of home call is positive for education (50.2 percent) and quality of life (56.5 percent), with a neutral impact on patient care (66.7 percent). Under the Council’s increasing regulations, home call provides a balance of education and patient care appropriate for training in plastic and reconstructive surgery. (Plast. Reconstr. Surg. 133: 1295, 2014.)
THE EVOLUTION OF DUTY HOUR REFORM As a result of concerns about patient safety and physician fatigue, regulation of resident duty hours has received significant attention in the public media as well as prominent medical literature.1–5 While the death of Libby Zion in 1983 is often considered the sentinel event in the history of duty hour reform, the first national standards From the Department of Plastic Surgery, Rhode Island Hospital; and the Warren Alpert Medical School, Brown University. Received for publication September 6, 2013; accepted November 12, 2013. Presented at the Plastic Surgery Research Council 58th Annual Meeting, in Los Angeles, California, May 4, 2013; and at the 54th Annual Meeting of the New England Society of Plastic and Reconstructive Surgeons, in Newport, Rhode Island, June 1, 2013. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000128
for resident duty hours were not implemented by the Accreditation Council for Graduate Medical Education until 2003. At that time, the Council’s Common Program Requirements required that residents work no more than 80 hours and must have at least 1 day off each week (both averaged over a 4-week period). These regulations also limited residents to a maximum of 30 consecutive hours in a single shift.6 After implementation, Disclosure: The authors have no financial interest to declare in relation to the content of this article.
A Video Discussion by Drs. Eberlin, Unger, Patel, Agko, and Amalfi accompanies this article. Go to PRSJournal.com and click on “Video Discussions” in the “Videos” tab to watch.
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Plastic and Reconstructive Surgery • May 2014 numerous studies were unable to identify consistently positive effects on resident education, medical errors, or patient safety.7–18 Despite the lack of consensus regarding a positive impact from 2003 duty hour regulations, the Council proposed further restrictions in 2010.19 These regulations were developed in response to public pressure and recommendations by the Institute of Medicine.20,21 The proposed regulations were implemented on July 1, 2011, despite concerns voiced by program directors and residents in various specialties.22–24 Surgeons and surgical residents voiced some of the most significant criticism before implementation.25–27 The 2011 standards limit first-year residents (interns, postgraduate year 1) to 16-hour duty periods and require that they have direct (on-site) supervision available at all times. By definition, this rule prohibits interns from taking an independent, 24-hour call. This rule may also be interpreted to mean that interns cannot be assigned to home call, where on-site supervision is not immediately available. More senior residents, defined by the Council to be in their second postgraduate year or greater, are now strictly limited to 24-hour consecutive duty periods (in the hospital), with an additional 4 hours allowed for sign-out, care of a critically ill patient or unique, extenuating circumstances. In addition, all residents must now have at least 10 hours free of clinical responsibility between shifts and must be off duty for at least 14 hours after a 24-hour on-call period.28 Although the plastic surgery residency review committee acknowledges that senior residents in their final years of training (independent years 1, 2, or 3 and integrated postgraduate years 4, 5, and 6) “must be prepared to enter unsupervised practice and care for patients over irregular and extended periods,” only “events of exceptional educational value” are allowed exceptions for duty hour violations, and these circumstances must be monitored by the program director.29 Studies that have been conducted after implementation of the 2011 duty hour standards have found generally negative views regarding the impact on education as well as quality and continuity of patient care; however, there is some suggestion that resident quality of life may be improved.30–34
DUTY HOURS AND PLASTIC SURGERY TRAINING Although duty hour reform within the realm of medical and general surgical training has been discussed extensively,35–42 literature regarding
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plastic surgery training has been more limited. In an editorial from Plastic and Reconstructive Surgery shortly before implementation of the 2003 Common Program Requirements, Rohrich and colleagues identified numerous concerns that included decreased continuity of care, worsened resident education, resident dissatisfaction, and expensive infrastructure changes (e.g., hiring midlevel providers). It is not surprising that many of these concerns seem to have borne out in the previously cited postimplementation studies. In 2012, Luce43,44 described the paradox of “arbitrary work-hour limits” shifting the focus away from “a fundamental solution [to] the real issue, education versus service.” Until now, only two published studies have examined the impact of duty hours on plastic surgery training. The first looked at the experience of residents at one program 6 months after implementation of the 2003 duty hour standards. This study found generally beneficial effects of duty hour reform on patient care, clinical experiences, and resident quality of life.45 However, the validity of the data is questionable given the short time period from intervention to outcome measurement, as well as the small sample size within a single institution. A second study, which examined resident operative experience using a pre/post design with retrospective review of case logs, found no changes in plastic surgery operative volume after implementation of duty hours in 2003.46 No studies have been published looking at the impact of the 2011 Common Program Requirements on plastic surgery training.
HOME CALL: MINIMALLY REGULATED DUTY HOURS Plastic surgery is unique from more general areas of training with more acute care patients (e.g., internal medicine, general surgery) in the more frequent use of at-home call for residents. In 2003 and 2011, at-home call (home call) remained the least regulated aspect of resident duty hours. In fact, only four regulations exist for home call47 Table 1. ACGME Common Program Requirements (VI.G.8): At-Home Call 1. Not subject to the every-third-night limitation 2. Must have 1 day off (not on home call) every 7 days (averaged over 4 weeks) 3. Hours spent in the hospital count toward the 80-hour maximum but do not initiate an off-duty period 4. Must not be “so frequent or taxing as to preclude rest or reasonable personal time” ACGME, Accreditation Council for Graduate Medical Education.
Volume 133, Number 5 • Duty Hours and Home Call (Table 1). Accordingly, some authors have viewed home call as a means for avoiding duty hour limitations set forth in the Common Program Requirements.48 Very few studies have examined the impact of home call on training or patient care. A recently published study by Kastenberg and colleagues49 found no impact on perioperative outcomes when using home call for interns in a 10-year retrospective review. This study is the first published report examining home call and the impact on plastic surgery training and patient care from the perspective of residents and fellows (house staff).
METHODS A 30-question survey was developed from previous studies on duty hours and review of Accreditation Council for Graduate Medical Education Common Program Requirements.23,28,31,33 The questions were designed to assess house staff knowledge and approval of home call and duty hour regulations, as well as their perceptions regarding the impact of home call on patient care, resident education, and quality of life. We identified all 92 plastic surgery training programs in the United States through the Accreditation Council for Graduate Medical Education database; these included both integrated and independent program designs. We obtained contact information for residency program coordinators through the Council’s distribution list. In addition, we cross-referenced this information with the Accreditation Council for Graduate Medical Education and Electronic Residency Application Service databases; a broad Internet search was used to complete any missing information. After we obtained approval from the Rhode Island Hospital’s institutional review board for a multicenter survey, we sent email requests to individual program coordinators and asked them to distribute our anonymous, electronic survey to house staff at their respective institutions. Two individualized e-mail requests were made to each program coordinator asking for participation. The survey was administered between September and October of 2012, approximately 16 months after implementation of the 2011 Common Program Requirements. We constructed confidence intervals for each response using standard error of proportions. Statistical significance between mean proportions was determined by nonoverlapping 95 percent confidence intervals and then confirmed using two-proportion Z tests. We used the chi-square test to evaluate for significant differences between
independent groups. In addition, we calculated correlation coefficients for trends in variables that were treated as continuous (e.g., postgraduate year) rather than ordinal.
RESULTS Forty-one program coordinators agreed to distribute the survey to their house staff for a total sample of 367 residents and fellows. From this group, 214 unique responses were obtained (58.3 percent completion rate), 40 from independent residents and 174 from integrated residents. The respondents were well distributed among all postgraduate years. Men outnumbered women (58.9 percent versus 41.1 percent), and the majority of respondents reported two trainees per year in their programs (54.1 percent) (Table 2). Home Call Experience We began with a descriptive assessment of the home call experience. Nearly all house staff reported that they took home call (98.6 percent). We excluded from further analysis three interns in the sample who reported that they took only traditional in-house call. The majority of house staff reported that they took first call (76.1 percent), indicating they are the primary house officer on call for the service. Not surprisingly, there was a trend toward more backup call (second call) in more senior residents (Pearson correlation, R2 = 0.90). Using a subjective scale, most respondents stated that they “rarely” or “never” remain (74.4 percent) at the hospital instead of going home. The average number of pages or telephone Table 2. Respondent Demographics Variable Sex Male Female Program size (trainees/year) 1 2 3 4 Not reported Year of training PGY-1 PGY-2 PGY-3 PGY-4 PGY-5 PGY-6 First-year fellow (fellow 1) Second-year fellow (fellow 2) Third-year fellow (fellow 3) Not reported
No. (%) 126 (58.9) 88 (41.1) 35 (16.9) 112 (54.1) 39 (18.8) 21 (10.1) 7 (3.4) 17 (8.0) 30 (14.2) 27 (12.7) 42 (19.8) 32 (15.1) 24 (11.3) 17 (8.0) 16 (7.5) 7 (3.3) 2 (0.9)
PGY, postgraduate year.
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Plastic and Reconstructive Surgery • May 2014 calls each night varied, but the plurality reported six to nine calls (37.9 percent). Information was not collected for how often these pages resulted directly in return to the hospital; however, the majority of residents (83.6 percent) reported they are “mostly” or “always” called back into the hospital after leaving (Fig. 1). Most of the respondents (66.7 percent) reported taking call on average every third or fourth night. When asked about call frequency, about half of trainees (50.7 percent) disagreed with the statement “I take call at home too frequently.” Although junior residents were more likely than senior residents to report feeling that call frequency was too great (R2 = 0.88), no significant differences were noted in call frequency by postgraduate year. Similar correlations between negative perceptions of call frequency (i.e., call is “too” frequent) were noted for busier call services (e.g., >10 pages per night; OR, 1.81) and greater on-call frequency (e.g., daily or every other day; OR, 3.69). Understanding of Home Call Regulations Despite the relatively limited number of regulations defining home call, 63.3 percent of residents agreed with the statement “Home call regulations are vague.” However, a linear trend showing greater disagreement with this statement in more senior residents (R2 = 0.96) suggests that understanding of the regulations improves with seniority and experience.
Nevertheless, 46.6 percent of postgraduate year 6 residents still reported that home call regulations are vague. A plurality of respondents agreed that “there is enough [Accreditation Council for Graduate Medical Education] regulation of home call” (44.9 percent); we found increasing agreement with this statement with greater postgraduate seniority (R2 = 0.94). Finally, the majority of residents reported that “there is adequate oversight of the duty hours by their programs” (56.5 percent), again with increasing agreement in more senior residents (R2 = 0.95). Compliance Several earlier studies have noted problems regarding substantial resident noncompliance with Accreditation Council for Graduate Medical Education duty hours standards.50–52 When we asked residents, “In general, how compliant are you with ACGME regulations?” we identified findings similar to those of earlier studies using a subjective scale. The question provided an estimated percentage compliance for each of the five Likert-scale responses ranging from “never” (0 percent) to “always” (100 percent). Using a previously described standard, noncompliance was defined as any response not indicating “always compliant.”50 Less than a quarter (23.2 percent) of residents in this survey said they were “always” compliant with duty hour regulations. Noncompliance was noted to be greater for house staff at
Fig. 1. Home call experience. Time in the hospital and time at home. Respondents were asked to answer: “On average, how often….”
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Fig. 2. Most common violations of duty hour regulations.
Fig. 3. Reported reasons for duty hour violations.
programs with fewer than two trainees per year (OR, 2.2; p < 0.05). Residents primarily attributed noncompliance to violation of 24 consecutive hours, followed by 80-hour violations and then days off each week (Fig. 2). The primary reason reported for noncompliance was operative clinical care (Fig. 3). Perceived Impact of Home Call We examined the perceived impact of home call on patient safety, resident education and quality of
life (Table 3). The majority of residents (66.7 percent) reported a neutral impact on patient safety, though significantly more reported a positive impact than a negative impact (OR, 5.35). Looking at related variables, most respondents reported they are adequately supervised (68.6 percent) and that the acuity of patients is appropriate for home call (93.2 percent). In addition, a majority of residents perceived a positive impact of home call on education (50.2 percent). Finally, most residents felt that home call is convenient (71.5 percent) and
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Plastic and Reconstructive Surgery • May 2014 Table 3. Perceived Impact of Home Call Respondents, % (95 percent CI) Positive
Neutral
Safety of patient care Resident education Resident quality of life
29.5 (23.4–35.6) 50.2 (43.5–56.9) 56.5 (49.9–63.2)*
66.7 (60.4–73.0)* 44.5 (39.5–50.5) 32.9 (26.6–39.1)
7.2 (3.8–10.7) 5.3 (2.3–8.3) 14.0 (9.4–18.7)
Negative
I have time for rest and personal responsibilities. Home call is convenient. ACGME rules for home call are vague. There is enough ACGME regulation of home call. There is enough oversight of home call by my program. I take call at home TOO frequently. I have enough time for rest and personal responsibilities. I am always adequately supervised. My program could not function without home call. Home call is a way of avoiding work hour restrictions. The acuity of my patients is appropriate for home call. Home call is convenient. Acuity of my patients is appropriate for home call.
Agree 52.7 (46.0–59.3)* 71.5 (65.4–77.5)* 63.3 (56.8–69.7)* 44.9 (38.3–51.6) 56.5 (49.9–63.2)* 19.3 (14.0–24.6) 52.7 (46.0–59.3)* 68.6 (62.4–74.8)* 91.8 (88.1–95.5)* 71.5 (65.4–77.5)* 93.2 (89.9–96.6)* 71.5 (65.4–77.5)* 93.2 (89.9–96.6)*
Neutral 30.0 (23.8–36.1) 22.2 (16.7–27.8) 24.2 (18.4–29.9) 32.9 (26.6–39.1) 28.5 (22.5–34.6) 33.3 (27.0–39.6) 30.0 (23.8–36.1) 26.6 (20.7–32.5) 8.7 (4.9–12.5) 12.1 (7.7–16.4) 8.2 (4.5–11.9) 22.2 (16.7–27.8) 8.2 (4.5–11.9)
Disagree 20.8 (15.3–26.2) 9.7 (5.7–13.6) 15.9 (11.0–20.8) 25.1 (19.3–30.9) 18.4 (13.2–23.5) 50.7 (44.0–57.4)* 20.8 (15.3–26.2) 7.7 (4.2–11.3) 2.9 (0.7–5.1) 19.8 (14.5–25.1) 1.9 (0.1–3.8) 9.7 (5.7–13.6) 1.9 (0.1–3.8)
ACGME, Accreditation Council for Graduate Medical Education. *Statistically significant response (α = 0.05) by nonoverlapping 95 percent confidence intervals.
that they have time for rest and personal responsibilities (52.7 percent), and overall reported a positive impact on quality of life (56.5 percent). Postgraduate year was identified as an independent factor associated with significant differences in the perceived impact of home call. Linear trends were noted, with senior residents less likely to report a negative impact on patient safety (R2 = 0.66), more likely to feel adequately supervised (R2 = 0.96), and more likely to report adequate time for rest (R2 = 0.87). Similar trends were seen for call order, which was noted to be covariate with postgraduate year, providing a surrogate measure for reliability of the survey questions. Residents on backup call were much more likely to report a beneficial impact on patient safety (OR, 2.14), adequate supervision (OR, 5.08), and time for rest (OR, 1.86).
DISCUSSION Although many residents reported feeling that “home call is a way of avoiding duty hour restrictions” (71.5 percent), the majority (92.3 percent) reported that they would prefer home call over in-house call. They generally reported that home call is convenient, safe, and positive in terms of the resident educational experience. While most residents felt that home call rules are vague, they also felt that there is enough regulation by the Accreditation Council for Graduate Medical Education and enough oversight of duty hours by their programs. Almost all residents (91.2 percent) stated that their program could not function without home call.
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As a descriptive study, we found that most plastic surgery residents take at-home call. These trainees are on call roughly every third or fourth night, and although call duties vary, most residents go home when they are on call, even if they are frequently called back into the hospital. Most residents feel that the frequency of call is appropriate. Although a minority of residents reported that they are “always” compliant with duty hour regulations, many reported that their violations were a result of clinical care, which was most often operative. On the basis of our findings, as well as direct experience, at-home call appears to be a more realistic reflection of an attending plastic surgeon’s practice. In line with the philosophy of graduated responsibility, the results of this study indicate that more senior residents may have a better appreciation of this reality, as they were more likely to report more positive perceptions of home call. On the other hand, this finding may be related to more positive feelings reported by residents on backup call, who are also more likely to be senior residents. Nevertheless, the function of backup call is similar to attending surgeons, at least at academic medical centers with house officers, and offers another dimension to the clinical education of a resident. This study, as with all cross-sectional cohort surveys, has a number of weaknesses. First, despite a good survey response rate (58.3 percent), we reached approximately half of all U.S. plastic surgery residents (50.7 percent) with our approach. Therefore, this sample represents 29.6 percent of all plastic surgery residents in the United States,
Volume 133, Number 5 • Duty Hours and Home Call so the potential for nonresponse bias must be acknowledged. It is possible that selection bias occurred through program coordinators in choosing whether or not to distribute the survey. However, the sample was ultimately drawn by choice of participating program coordinators, representing a nearly random sample of residents. Accordingly, the survey response rate of nearly 60 percent is reflective of quality sampling and methodology, thereby minimizing this concern of nonresponse bias.54 Survey research can also be limited by interpretation, recall, and social desirability bias, which we sought to minimize using a carefully designed, piloted, and anonymous survey. Finally, the results of this study reflect the perceptions of residents and not the actual working conditions or impact of home call on the measured variables. Therefore, the results must be interpreted as a subjective assessment of the variables measured in the study. Despite these weaknesses, this study presents the first data regarding home call and Accreditation Council for Graduate Medical Education regulations in plastic surgery from a large national sample. The results demonstrate support of home call in plastic surgery training from the perceived impact and direct opinions of residents. In the era of duty hour reform, home call provides a means for residents to participate in daytime educational activities while staffing overnight consultation services and managing patients from home. The home call experience may more realistically reflect an attending surgeon’s practice and prepares house staff for independent care of patients at the completion of residency, which is the ultimate goal of graduate medical education. Brian C. Drolet, M.D. Rhode Island Hospital 2 Dudley Street, Coop 500 Providence, R.I. 02903 [email protected]
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hour limitations in surgical training programs. Arch Surg. 2003;138:663–669; discussion 669. 39. Izu BS, Johnson RM, Termuhlen PM, Little AG. Effect of the 30-hour work limit on resident experience and education. J Surg Educ. 2007;64:361–364. 40. Everett CB, Helmer SD, Osland JS, Smith RS. General surgery resident attrition and the 80-hour workweek. Am J Surg. 2007;194:751–756; discussion 756. 41. Breen E, Irani JL, Mello MM, Whang EE, Zinner MJ, Ashley SW. The future of surgery: Today’s residents speak. Curr Surg. 2005;62:543–546. 42. Brasel KJ, Pierre AL, Weigelt JA. Resident work hours: What they are really doing. Arch Surg. 2004;139:490–493; discussion 493. 43. Luce EA. Beyond working hours: Part II. Incentive to improve. Plast Reconstr Surg. 2012;129:717e–720e. 44. Luce EA. Beyond working hours: Part I. Genesis and current difficulties. Plast Reconstr Surg. 2012;129:1015–1021. 45. Basu CB, Chen LM, Hollier LH Jr, Shenaq SM. The effect of the Accreditation Council for Graduate Medical Education duty hours policy on plastic surgery resident education and patient care: An outcomes study. Plast Reconstr Surg. 2004;114:1878–1886. 46. Simien C, Holt KD, Richter TH, et al. Resident operative experience in general surgery, plastic surgery, and urology 5 years after implementation of the ACGME duty hour policy. Ann Surg. 2010;252:383–389. 47. Common Program Requirements. Accreditation Council for Graduate Medical Education. 2013. Available at: http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ ProgramRequirements/CPRs2013.pdf). Accessed May 11, 2013. 48. Dalton C. Use of at-home call by residency programs. In: Reports of the Council on Medical Education: American Medical Association Council on Medical Education; 2008:171–200. 49. Kastenberg ZJ, Rhoads KF, Melcher ML, Wren SM. The influence of intern home call on objectively measured perioperative outcomes. JAMA Surg. 2013;148:347–351. 50. Drolet BC, Schwede M, Bishop KD, Fischer SA. Compliance and falsification of duty hours: Reports from residents and program directors. J Grad Med Educ. 2013;5:368–373. 51. Tabrizian P, Rajhbeharrysingh U, Khaitov S, Divino CM. Persistent noncompliance with the work-hour regulation. Arch Surg. 2011;146:175–178. 52. Landrigan CP, Barger LK, Cade BE, Ayas NT, Czeisler CA. Interns’ compliance with accreditation council for graduate medical education work-hour limits. JAMA 2006;296:1063–1070. 53. Johnson TP, Wislar JS. Response rates and nonresponse errors in surveys. JAMA 2012;307:1805–1806.
Background: Although resident duty hours are strictly regulated by the Accreditation Council for Graduate Medical Education, there are fewer restrictions on at-home call for residents. To date, no studies have examined the experience of home call for plastic surgery trainees or the impact of home call on patient care and education in plastic surgery. Methods: The authors distributed an anonymous electronic survey to plastic surgery trainees at 41 accredited programs. They sought to produce a descriptive assessment of home call and to evaluate the perceived impact of home call on training and patient care. Results: A total of 214 responses were obtained (58.3 percent completion rate). Nearly all trainees reported taking home call (98.6 percent), with 66.7 percent reporting call frequency every third or fourth night. Most respondents (63.3 percent) felt that home call regulations are vague but that Council regulation (44.9 percent) and programmatic oversight (56.5 percent) are adequate. Most (91.2 percent) believe their program could not function without home call and that home call helps to avoid strict duty hour restrictions (71.5 percent). Nearly all respondents (92.3 percent) preferred home call to in-house call. Conclusions: This is the first study to examine how plastic surgery residents experience and perceive home call within the framework of Accreditation Council for Graduate Medical Education duty hour regulations. Most trainees feel the impact of home call is positive for education (50.2 percent) and quality of life (56.5 percent), with a neutral impact on patient care (66.7 percent). Under the Council’s increasing regulations, home call provides a balance of education and patient care appropriate for training in plastic and reconstructive surgery. (Plast. Reconstr. Surg. 133: 1295, 2014.)
THE EVOLUTION OF DUTY HOUR REFORM As a result of concerns about patient safety and physician fatigue, regulation of resident duty hours has received significant attention in the public media as well as prominent medical literature.1–5 While the death of Libby Zion in 1983 is often considered the sentinel event in the history of duty hour reform, the first national standards From the Department of Plastic Surgery, Rhode Island Hospital; and the Warren Alpert Medical School, Brown University. Received for publication September 6, 2013; accepted November 12, 2013. Presented at the Plastic Surgery Research Council 58th Annual Meeting, in Los Angeles, California, May 4, 2013; and at the 54th Annual Meeting of the New England Society of Plastic and Reconstructive Surgeons, in Newport, Rhode Island, June 1, 2013. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000128
for resident duty hours were not implemented by the Accreditation Council for Graduate Medical Education until 2003. At that time, the Council’s Common Program Requirements required that residents work no more than 80 hours and must have at least 1 day off each week (both averaged over a 4-week period). These regulations also limited residents to a maximum of 30 consecutive hours in a single shift.6 After implementation, Disclosure: The authors have no financial interest to declare in relation to the content of this article.
A Video Discussion by Drs. Eberlin, Unger, Patel, Agko, and Amalfi accompanies this article. Go to PRSJournal.com and click on “Video Discussions” in the “Videos” tab to watch.
www.PRSJournal.com
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Plastic and Reconstructive Surgery • May 2014 numerous studies were unable to identify consistently positive effects on resident education, medical errors, or patient safety.7–18 Despite the lack of consensus regarding a positive impact from 2003 duty hour regulations, the Council proposed further restrictions in 2010.19 These regulations were developed in response to public pressure and recommendations by the Institute of Medicine.20,21 The proposed regulations were implemented on July 1, 2011, despite concerns voiced by program directors and residents in various specialties.22–24 Surgeons and surgical residents voiced some of the most significant criticism before implementation.25–27 The 2011 standards limit first-year residents (interns, postgraduate year 1) to 16-hour duty periods and require that they have direct (on-site) supervision available at all times. By definition, this rule prohibits interns from taking an independent, 24-hour call. This rule may also be interpreted to mean that interns cannot be assigned to home call, where on-site supervision is not immediately available. More senior residents, defined by the Council to be in their second postgraduate year or greater, are now strictly limited to 24-hour consecutive duty periods (in the hospital), with an additional 4 hours allowed for sign-out, care of a critically ill patient or unique, extenuating circumstances. In addition, all residents must now have at least 10 hours free of clinical responsibility between shifts and must be off duty for at least 14 hours after a 24-hour on-call period.28 Although the plastic surgery residency review committee acknowledges that senior residents in their final years of training (independent years 1, 2, or 3 and integrated postgraduate years 4, 5, and 6) “must be prepared to enter unsupervised practice and care for patients over irregular and extended periods,” only “events of exceptional educational value” are allowed exceptions for duty hour violations, and these circumstances must be monitored by the program director.29 Studies that have been conducted after implementation of the 2011 duty hour standards have found generally negative views regarding the impact on education as well as quality and continuity of patient care; however, there is some suggestion that resident quality of life may be improved.30–34
DUTY HOURS AND PLASTIC SURGERY TRAINING Although duty hour reform within the realm of medical and general surgical training has been discussed extensively,35–42 literature regarding
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plastic surgery training has been more limited. In an editorial from Plastic and Reconstructive Surgery shortly before implementation of the 2003 Common Program Requirements, Rohrich and colleagues identified numerous concerns that included decreased continuity of care, worsened resident education, resident dissatisfaction, and expensive infrastructure changes (e.g., hiring midlevel providers). It is not surprising that many of these concerns seem to have borne out in the previously cited postimplementation studies. In 2012, Luce43,44 described the paradox of “arbitrary work-hour limits” shifting the focus away from “a fundamental solution [to] the real issue, education versus service.” Until now, only two published studies have examined the impact of duty hours on plastic surgery training. The first looked at the experience of residents at one program 6 months after implementation of the 2003 duty hour standards. This study found generally beneficial effects of duty hour reform on patient care, clinical experiences, and resident quality of life.45 However, the validity of the data is questionable given the short time period from intervention to outcome measurement, as well as the small sample size within a single institution. A second study, which examined resident operative experience using a pre/post design with retrospective review of case logs, found no changes in plastic surgery operative volume after implementation of duty hours in 2003.46 No studies have been published looking at the impact of the 2011 Common Program Requirements on plastic surgery training.
HOME CALL: MINIMALLY REGULATED DUTY HOURS Plastic surgery is unique from more general areas of training with more acute care patients (e.g., internal medicine, general surgery) in the more frequent use of at-home call for residents. In 2003 and 2011, at-home call (home call) remained the least regulated aspect of resident duty hours. In fact, only four regulations exist for home call47 Table 1. ACGME Common Program Requirements (VI.G.8): At-Home Call 1. Not subject to the every-third-night limitation 2. Must have 1 day off (not on home call) every 7 days (averaged over 4 weeks) 3. Hours spent in the hospital count toward the 80-hour maximum but do not initiate an off-duty period 4. Must not be “so frequent or taxing as to preclude rest or reasonable personal time” ACGME, Accreditation Council for Graduate Medical Education.
Volume 133, Number 5 • Duty Hours and Home Call (Table 1). Accordingly, some authors have viewed home call as a means for avoiding duty hour limitations set forth in the Common Program Requirements.48 Very few studies have examined the impact of home call on training or patient care. A recently published study by Kastenberg and colleagues49 found no impact on perioperative outcomes when using home call for interns in a 10-year retrospective review. This study is the first published report examining home call and the impact on plastic surgery training and patient care from the perspective of residents and fellows (house staff).
METHODS A 30-question survey was developed from previous studies on duty hours and review of Accreditation Council for Graduate Medical Education Common Program Requirements.23,28,31,33 The questions were designed to assess house staff knowledge and approval of home call and duty hour regulations, as well as their perceptions regarding the impact of home call on patient care, resident education, and quality of life. We identified all 92 plastic surgery training programs in the United States through the Accreditation Council for Graduate Medical Education database; these included both integrated and independent program designs. We obtained contact information for residency program coordinators through the Council’s distribution list. In addition, we cross-referenced this information with the Accreditation Council for Graduate Medical Education and Electronic Residency Application Service databases; a broad Internet search was used to complete any missing information. After we obtained approval from the Rhode Island Hospital’s institutional review board for a multicenter survey, we sent email requests to individual program coordinators and asked them to distribute our anonymous, electronic survey to house staff at their respective institutions. Two individualized e-mail requests were made to each program coordinator asking for participation. The survey was administered between September and October of 2012, approximately 16 months after implementation of the 2011 Common Program Requirements. We constructed confidence intervals for each response using standard error of proportions. Statistical significance between mean proportions was determined by nonoverlapping 95 percent confidence intervals and then confirmed using two-proportion Z tests. We used the chi-square test to evaluate for significant differences between
independent groups. In addition, we calculated correlation coefficients for trends in variables that were treated as continuous (e.g., postgraduate year) rather than ordinal.
RESULTS Forty-one program coordinators agreed to distribute the survey to their house staff for a total sample of 367 residents and fellows. From this group, 214 unique responses were obtained (58.3 percent completion rate), 40 from independent residents and 174 from integrated residents. The respondents were well distributed among all postgraduate years. Men outnumbered women (58.9 percent versus 41.1 percent), and the majority of respondents reported two trainees per year in their programs (54.1 percent) (Table 2). Home Call Experience We began with a descriptive assessment of the home call experience. Nearly all house staff reported that they took home call (98.6 percent). We excluded from further analysis three interns in the sample who reported that they took only traditional in-house call. The majority of house staff reported that they took first call (76.1 percent), indicating they are the primary house officer on call for the service. Not surprisingly, there was a trend toward more backup call (second call) in more senior residents (Pearson correlation, R2 = 0.90). Using a subjective scale, most respondents stated that they “rarely” or “never” remain (74.4 percent) at the hospital instead of going home. The average number of pages or telephone Table 2. Respondent Demographics Variable Sex Male Female Program size (trainees/year) 1 2 3 4 Not reported Year of training PGY-1 PGY-2 PGY-3 PGY-4 PGY-5 PGY-6 First-year fellow (fellow 1) Second-year fellow (fellow 2) Third-year fellow (fellow 3) Not reported
No. (%) 126 (58.9) 88 (41.1) 35 (16.9) 112 (54.1) 39 (18.8) 21 (10.1) 7 (3.4) 17 (8.0) 30 (14.2) 27 (12.7) 42 (19.8) 32 (15.1) 24 (11.3) 17 (8.0) 16 (7.5) 7 (3.3) 2 (0.9)
PGY, postgraduate year.
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Plastic and Reconstructive Surgery • May 2014 calls each night varied, but the plurality reported six to nine calls (37.9 percent). Information was not collected for how often these pages resulted directly in return to the hospital; however, the majority of residents (83.6 percent) reported they are “mostly” or “always” called back into the hospital after leaving (Fig. 1). Most of the respondents (66.7 percent) reported taking call on average every third or fourth night. When asked about call frequency, about half of trainees (50.7 percent) disagreed with the statement “I take call at home too frequently.” Although junior residents were more likely than senior residents to report feeling that call frequency was too great (R2 = 0.88), no significant differences were noted in call frequency by postgraduate year. Similar correlations between negative perceptions of call frequency (i.e., call is “too” frequent) were noted for busier call services (e.g., >10 pages per night; OR, 1.81) and greater on-call frequency (e.g., daily or every other day; OR, 3.69). Understanding of Home Call Regulations Despite the relatively limited number of regulations defining home call, 63.3 percent of residents agreed with the statement “Home call regulations are vague.” However, a linear trend showing greater disagreement with this statement in more senior residents (R2 = 0.96) suggests that understanding of the regulations improves with seniority and experience.
Nevertheless, 46.6 percent of postgraduate year 6 residents still reported that home call regulations are vague. A plurality of respondents agreed that “there is enough [Accreditation Council for Graduate Medical Education] regulation of home call” (44.9 percent); we found increasing agreement with this statement with greater postgraduate seniority (R2 = 0.94). Finally, the majority of residents reported that “there is adequate oversight of the duty hours by their programs” (56.5 percent), again with increasing agreement in more senior residents (R2 = 0.95). Compliance Several earlier studies have noted problems regarding substantial resident noncompliance with Accreditation Council for Graduate Medical Education duty hours standards.50–52 When we asked residents, “In general, how compliant are you with ACGME regulations?” we identified findings similar to those of earlier studies using a subjective scale. The question provided an estimated percentage compliance for each of the five Likert-scale responses ranging from “never” (0 percent) to “always” (100 percent). Using a previously described standard, noncompliance was defined as any response not indicating “always compliant.”50 Less than a quarter (23.2 percent) of residents in this survey said they were “always” compliant with duty hour regulations. Noncompliance was noted to be greater for house staff at
Fig. 1. Home call experience. Time in the hospital and time at home. Respondents were asked to answer: “On average, how often….”
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Fig. 2. Most common violations of duty hour regulations.
Fig. 3. Reported reasons for duty hour violations.
programs with fewer than two trainees per year (OR, 2.2; p < 0.05). Residents primarily attributed noncompliance to violation of 24 consecutive hours, followed by 80-hour violations and then days off each week (Fig. 2). The primary reason reported for noncompliance was operative clinical care (Fig. 3). Perceived Impact of Home Call We examined the perceived impact of home call on patient safety, resident education and quality of
life (Table 3). The majority of residents (66.7 percent) reported a neutral impact on patient safety, though significantly more reported a positive impact than a negative impact (OR, 5.35). Looking at related variables, most respondents reported they are adequately supervised (68.6 percent) and that the acuity of patients is appropriate for home call (93.2 percent). In addition, a majority of residents perceived a positive impact of home call on education (50.2 percent). Finally, most residents felt that home call is convenient (71.5 percent) and
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Plastic and Reconstructive Surgery • May 2014 Table 3. Perceived Impact of Home Call Respondents, % (95 percent CI) Positive
Neutral
Safety of patient care Resident education Resident quality of life
29.5 (23.4–35.6) 50.2 (43.5–56.9) 56.5 (49.9–63.2)*
66.7 (60.4–73.0)* 44.5 (39.5–50.5) 32.9 (26.6–39.1)
7.2 (3.8–10.7) 5.3 (2.3–8.3) 14.0 (9.4–18.7)
Negative
I have time for rest and personal responsibilities. Home call is convenient. ACGME rules for home call are vague. There is enough ACGME regulation of home call. There is enough oversight of home call by my program. I take call at home TOO frequently. I have enough time for rest and personal responsibilities. I am always adequately supervised. My program could not function without home call. Home call is a way of avoiding work hour restrictions. The acuity of my patients is appropriate for home call. Home call is convenient. Acuity of my patients is appropriate for home call.
Agree 52.7 (46.0–59.3)* 71.5 (65.4–77.5)* 63.3 (56.8–69.7)* 44.9 (38.3–51.6) 56.5 (49.9–63.2)* 19.3 (14.0–24.6) 52.7 (46.0–59.3)* 68.6 (62.4–74.8)* 91.8 (88.1–95.5)* 71.5 (65.4–77.5)* 93.2 (89.9–96.6)* 71.5 (65.4–77.5)* 93.2 (89.9–96.6)*
Neutral 30.0 (23.8–36.1) 22.2 (16.7–27.8) 24.2 (18.4–29.9) 32.9 (26.6–39.1) 28.5 (22.5–34.6) 33.3 (27.0–39.6) 30.0 (23.8–36.1) 26.6 (20.7–32.5) 8.7 (4.9–12.5) 12.1 (7.7–16.4) 8.2 (4.5–11.9) 22.2 (16.7–27.8) 8.2 (4.5–11.9)
Disagree 20.8 (15.3–26.2) 9.7 (5.7–13.6) 15.9 (11.0–20.8) 25.1 (19.3–30.9) 18.4 (13.2–23.5) 50.7 (44.0–57.4)* 20.8 (15.3–26.2) 7.7 (4.2–11.3) 2.9 (0.7–5.1) 19.8 (14.5–25.1) 1.9 (0.1–3.8) 9.7 (5.7–13.6) 1.9 (0.1–3.8)
ACGME, Accreditation Council for Graduate Medical Education. *Statistically significant response (α = 0.05) by nonoverlapping 95 percent confidence intervals.
that they have time for rest and personal responsibilities (52.7 percent), and overall reported a positive impact on quality of life (56.5 percent). Postgraduate year was identified as an independent factor associated with significant differences in the perceived impact of home call. Linear trends were noted, with senior residents less likely to report a negative impact on patient safety (R2 = 0.66), more likely to feel adequately supervised (R2 = 0.96), and more likely to report adequate time for rest (R2 = 0.87). Similar trends were seen for call order, which was noted to be covariate with postgraduate year, providing a surrogate measure for reliability of the survey questions. Residents on backup call were much more likely to report a beneficial impact on patient safety (OR, 2.14), adequate supervision (OR, 5.08), and time for rest (OR, 1.86).
DISCUSSION Although many residents reported feeling that “home call is a way of avoiding duty hour restrictions” (71.5 percent), the majority (92.3 percent) reported that they would prefer home call over in-house call. They generally reported that home call is convenient, safe, and positive in terms of the resident educational experience. While most residents felt that home call rules are vague, they also felt that there is enough regulation by the Accreditation Council for Graduate Medical Education and enough oversight of duty hours by their programs. Almost all residents (91.2 percent) stated that their program could not function without home call.
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As a descriptive study, we found that most plastic surgery residents take at-home call. These trainees are on call roughly every third or fourth night, and although call duties vary, most residents go home when they are on call, even if they are frequently called back into the hospital. Most residents feel that the frequency of call is appropriate. Although a minority of residents reported that they are “always” compliant with duty hour regulations, many reported that their violations were a result of clinical care, which was most often operative. On the basis of our findings, as well as direct experience, at-home call appears to be a more realistic reflection of an attending plastic surgeon’s practice. In line with the philosophy of graduated responsibility, the results of this study indicate that more senior residents may have a better appreciation of this reality, as they were more likely to report more positive perceptions of home call. On the other hand, this finding may be related to more positive feelings reported by residents on backup call, who are also more likely to be senior residents. Nevertheless, the function of backup call is similar to attending surgeons, at least at academic medical centers with house officers, and offers another dimension to the clinical education of a resident. This study, as with all cross-sectional cohort surveys, has a number of weaknesses. First, despite a good survey response rate (58.3 percent), we reached approximately half of all U.S. plastic surgery residents (50.7 percent) with our approach. Therefore, this sample represents 29.6 percent of all plastic surgery residents in the United States,
Volume 133, Number 5 • Duty Hours and Home Call so the potential for nonresponse bias must be acknowledged. It is possible that selection bias occurred through program coordinators in choosing whether or not to distribute the survey. However, the sample was ultimately drawn by choice of participating program coordinators, representing a nearly random sample of residents. Accordingly, the survey response rate of nearly 60 percent is reflective of quality sampling and methodology, thereby minimizing this concern of nonresponse bias.54 Survey research can also be limited by interpretation, recall, and social desirability bias, which we sought to minimize using a carefully designed, piloted, and anonymous survey. Finally, the results of this study reflect the perceptions of residents and not the actual working conditions or impact of home call on the measured variables. Therefore, the results must be interpreted as a subjective assessment of the variables measured in the study. Despite these weaknesses, this study presents the first data regarding home call and Accreditation Council for Graduate Medical Education regulations in plastic surgery from a large national sample. The results demonstrate support of home call in plastic surgery training from the perceived impact and direct opinions of residents. In the era of duty hour reform, home call provides a means for residents to participate in daytime educational activities while staffing overnight consultation services and managing patients from home. The home call experience may more realistically reflect an attending surgeon’s practice and prepares house staff for independent care of patients at the completion of residency, which is the ultimate goal of graduate medical education. Brian C. Drolet, M.D. Rhode Island Hospital 2 Dudley Street, Coop 500 Providence, R.I. 02903 [email protected]
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5. Staiger DO, Auerbach DI, Buerhaus PI. Trends in the work hours of physicians in the United States. JAMA 2010;303:747–753. 6. Philibert I, Friedmann P, Williams WT; ACGME Work Group on Resident Duty Hours. Accreditation Council for Graduate Medical Education. New requirements for resident duty hours. JAMA 2002;288:1112–1114. 7. Volpp KG, Rosen AK, Rosenbaum PR, et al. Did duty hour reform lead to better outcomes among the highest risk patients? J Gen Intern Med. 2009;24:1149–1155. 8. Landrigan CP, Fahrenkopf AM, Lewin D, et al. Effects of the accreditation council for graduate medical education duty hour limits on sleep, work hours, and safety. Pediatrics 2008;122:250–258. 9. Fletcher KE, Underwood W 3rd, Davis SQ, Mangrulkar RS, McMahon LF Jr, Saint S. Effects of work hour reduction on residents’ lives: A systematic review. JAMA 2005;294:1088–1100. 10. Fletcher KE, Davis SQ, Underwood W, Mangrulkar RS, McMahon LF Jr, Saint S. Systematic review: Effects of resident work hours on patient safety. Ann Intern Med. 2004;141:851–857. 11. Baldwin K, Namdari S, Donegan D, Kamath AF, Mehta S. Early effects of resident work-hour restrictions on patient safety: A systematic review and plea for improved studies. J Bone Joint Surg Am. 2011;93:e5. 12. Howard DL, Silber JH, Jobes DR, Silber JH. Do regulations limiting residents’ work hours affect patient mortality? J Gen Intern Med. 2004;19:1–7. 13. Poulose BK, Ray WA, Arbogast PG, et al. Resident work hour limits and patient safety. Ann Surg. 2005;241:847–856; discussion 856. 14. Spencer AU, Teitelbaum DH. Impact of work-hour restrictions on residents’ operative volume on a subspecialty surgical service. J Am Coll Surg. 2005;200:670–676. 15. Griner D, Menon RP, Kotwall CA, Clancy TV, Hope WW. The eighty-hour workweek: Surgical attendings’ perspectives. J Surg Educ. 2010;67:25–31. 16. Borman KR, Jones AT, Shea JA. Duty hours, quality of care, and patient safety: General surgery resident perceptions. J Am Coll Surg. 2012;215:70–77; discussion 77. 17. de Virgilio C, Yaghoubian A, Lewis RJ, Stabile BE, Putnam BA. The 80-hour resident workweek does not adversely affect patient outcomes or resident education. Curr Surg. 2006;63:435–439; discussion 440. 18. Jamal MH, Rousseau MC, Hanna WC, Doi SA, Meterissian S, Snell L. Effect of the ACGME duty hours restrictions on surgical residents and faculty: A systematic review. Acad Med. 2011;86:34–42. 19. Proposed Duty Hours Standards. Task Force on Quality Care and Professionalism. 2010. Available at:http://acgme2010standards.org/pdf/Proposed_Standards.pdf). Accessed August 12, 2010. 20. Blum AB, Raiszadeh F, Shea S, et al. US public opinion regarding proposed limits on resident physician work hours. BMC Med. 2010;8:33. 21. Iglehart JK. Revisiting duty-hour limits: IOM recommendations for patient safety and resident education. N Engl J Med. 2008;359:2633–2635. 22. Drolet BC, Soh IY, Shultz PA, Fischer SA. A thematic review of resident commentary on duty hours and supervision regulations. J Grad Med Educ. 2012;4:454–459. 23. Drolet BC, Spalluto LB, Fischer SA. Residents’ perspectives on ACGME regulation of supervision and duty hours: A national survey. N Engl J Med. 2010;363:e34. 24. Antiel RM, Thompson SM, Reed DA, et al. ACGME d uty-hour recommendations: A national survey of residency program directors. N Engl J Med. 2010;363:e12.
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