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Published in Alumni Publications on January 01, 2012
From left, fourth-year medical student Meagan Mahoney, chief Surgery Resident Dr. Laura Vick, Dr. Thomas Helling, professor of surgery and division chief of general surgery, and third-year surgery resident Dr. Will Cauthen perform a recent procedure. Dr. Vick has since joined the faculty.
From left, fourth-year medical student Meagan Mahoney, chief Surgery Resident Dr. Laura Vick, Dr. Thomas Helling, professor of surgery and division chief of general surgery, and third-year surgery resident Dr. Will Cauthen perform a recent procedure. Dr. Vick has since joined the faculty.

UMMC study: Resident duty-hour restrictions curb surgical experience

By Jack Mazurak

Restrictions on the number of hours medical residents can work have left surgery trainees participating in fewer procedures and getting less experience in key roles, according to a study at the University of Mississippi Medical Center.

Dr. Emile Picarella was first author on a study about the effects of duty-hour restrictions, which he began as a general surgery trainee at UMMC. He completed his residency in 2011.
Dr. Emile Picarella was first author on a study about the effects of duty-hour restrictions, which he began as a general surgery trainee at UMMC. He completed his residency in 2011.

While the study’s findings are new, they point to issues teaching hospitals nationwide continue grappling with eight years into the duty-hour policy change.

The Accreditation Council for Graduate Medical Education, which sets standards for residency programs in the U.S., instituted duty-hour restrictions in 2003, limiting residents to 80 hours a week. The ACGME intended to improve training overall, reduce fatigue and decrease medical errors.

In response, teaching hospitals across the U.S. have reworked curriculums, shuffled schedules, upped their numbers of residency slots and added staff. All the while, they’ve had to provide quality care and positive outcomes for patients, stay within budget and produce well-educated doctors.

But fewer hours can mean less training. And the study adds another voice to a chorus questioning whether the quality of education has eroded.

“Since 2003, there’s been a lot of discussion on duty-hour restriction,” said Dr. Emile Picarella, first author on the study. “I think the focus should be, ‘Are we training people well enough to operate on patients without supervision?’ So it was our idea to take a peek at the numbers.”

According to the study, the total number of procedures performed annually per resident dropped by one third throughout seven years – from more than 1,627 procedures in 2002 to 1,107 in 2008.

“I think residents are still learning how to do procedures, but they aren’t getting as much experience in pre- and post-operative care,” Picarella said. “I’m sure that the attending physicians know whether or not a resident is able to do the surgery, but the question is whether the resident knows they’re capable to do it alone.”

Picarella, a general surgery trainee at UMMC when he launched the study, completed residency in 2011 and is in the second year of a three-year plastic surgery fellowship at the Medical Center. The Journal of Surgical Education published the study in its March-April (2011) issue.

Adjusting to the restrictions is no easy task, both within the department and institution-wide. In the complex webs that are teaching hospitals, pulling one strand moves a nexus of others.

“Duty-hour restrictions are a huge concern for those of us training surgeons,” said Dr. Marc Mitchell, chair of the Department of Surgery and co-author of the study. “We’re probably impacted more than other departments since surgery residents have always worked the most hours.”

Most professional associations believe surgery has reached the point of having to increase the length of the residency if work hours are decreased any more, he said.

On the patient-care side, some hospitals have hired staff, usually nurse practitioners, physicians’ assistants and hospitalists, to cover tasks residents once did. But that costs money and stresses budgets.

The Department of Surgery has added residency slots – now up to about 60 – both to accommodate duty-hour restrictions and the expansions in medical school class sizes.

“We’ve increased the number of preliminary spots and recently lengthened the internship for plastic surgery from two to three years,” Mitchell said.

But you’ve got to have the patient volume to support the costs of new staff and residency slots, he said. Dr. Shirley Schlessinger, associate dean for graduate medical education and chair of the Department of Medicine, said the School of Medicine added 51 new residency positions in the last eight years.

Though vital, the new, mostly hospital-funded slots also put pressure on budgets. Federal funding for medical residencies has remained flat since the mid-1990s.

The duty-hour restrictions also increased the number of patient handoffs from a caretaker on an outgoing shift to one on an incoming shift. Research shows handoffs are opportune times for errors because of lack of communication.

“There are so many intangibles involved in the care of a specific individual,” Schlessinger said. “We’ve created sets of rules to prevent errors that are designed to the lowest common denominator.”

She called the balance of priorities a dynamic tension.

“We educate to produce competent, quality physicians. At the same time we’re committed to patients for the quality of care, outcomes and safety, and supervision.”

The study documented a drop in the number of procedures that residents participated in as the first assistant surgeon. First-assistant cases fell from 441 per resident who finished the residency in 2002 to 110 per resident who finished in 2008.

Though often the first assistant is the surgeon with the least responsibility in the room, Picarella said the experience is key.

“First assistants can learn where to make the incision, how to handle tissue, dissection planes, handling of instruments, logistics, how to resect down to the surgery’s target place,” he said.

Simulation with mannequins, computer programs and other technology can help close that gap, but only so far.

“Simulation, particularly for minimally invasive procedures like endoscopy and laparoscopy, is one way we’re trying to make up for their participation in fewer procedures as first assistants,” Mitchell said.

Other avenues include adding cadaver labs, live-animal surgeries and, most drastically, lengthening residency programs. And all carry extra cost.

Institutionally, residency programs need to focus on covering the most important aspects of training and eliminating redundancy.

“I don’t think you can look at case numbers in isolation and think that’s the whole story,” Schlessinger said. “So the question is, how do we design curriculums where they get exposure to the variety of procedures they need rather than 80 hernia repairs?

“Each heart attack is different for the patient, but if a resident has handled 150 of them, that’s probably enough to know.”

And for total competency programs also need to consider the number of papers, presentations and research articles produced, along with lectures, grand rounds and other functions residents attend.

That sweet spot is a moving target. One resident may need more cases to feel competent than another. And technology keeps changing the business.

“Not only do you have to learn the more established methods, but also the newly established ones. There’s more to learn and less time,” Mitchell said.

As more specialists complete residencies under duty restrictions, the practice landscape will change. Mitchell said rather than seeing longer residencies, the number of subspecialties may increase, possibly hurting community hospitals without the patient volume or resources to hire subspecialists.

“That will affect the ability of smaller hospitals to have complete services and offer a broad range of procedures,” he said.

A different landscape could be good in some ways. Schlessinger takes a holistic view.

“I’m supportive of duty-hour restrictions because I do think it’s having a positive impact on the physicians we’re training,” she said. “Fifteen years from now, we’re going to see private practices evolve. In fact, we’re seeing it now.”

Many doctors finishing residency now have learned that they’re going to take better care of their patients if they are taking better care of themselves.

“We still need to keep patients at the forefront,” Schlessinger said. “It’s a balance between the doctors’ needs and the patient’s care. The patient-physician relationship is sacred and something we don’t want to lose as our practice evolves.”