Orthopaedic Training Focus A Perspective on the Effect of the 80-Hour Work Week: Has It Changed the Graduating Orthopaedic Resident?

Abstract Vincent D. Pellegrini, Jr, MD Orthopaedic residency education has changed substantially in recent decades because of the imposition of the 80-hour work week, a decrease in quality and quantity of general surgical education, regulations mandating closer trainee supervision, and an expansion of orthopaedic subspecialty rotations. These factors pose a challenge in efforts to prepare competent, confident, cautious, caring, and communicative orthopaedic residents within the traditional 5-year program. Evidence suggests that contemporary graduates are more intelligent, better balanced in life and work, and more in touch with humanistic aspects of medicine than were earlier graduates. Yet insufficient competence and confidence in surgical skills after residency and a lack of “ownership” of patient care have become an increasing concern of educators and trainees. The concept of 10,000 hours of deliberate practice to achieve mastery of a technical skill applies to orthopaedic residency education. A different approach to graduate medical education must address the critical minimum training time required to achieve the necessary skills to support independent medical and surgical practice. From the Department of Orthopaedics and the Musculoskeletal Institute, Medical University of South Carolina, Charleston, SC, and the Department of Bioengineering, Clemson he product of orthopaedic resi- defining them concisely. Others are University, Clemson, SC. Tdency is the subject of continu- more substantive and quantifiable. Dr. Pellegrini or an immediate family ous review and critical analysis. Nonetheless, few would argue that member has received royalties from, Characteristics of a graduating the orthopaedic residency process serves as a paid consultant to, and orthopaedic resident have long been has changed substantially, and most has received research or institutional a topic of vigorous discussion would agree that it needed to support from DePuy Synthes and serves as a board member, owner, among those who have passionately change. I concur with both of those officer, or committee member of the dedicated a career to resident edu- points. What may be less apparent, American Orthopaedic Association, cation in our specialty. Moreover, and more controversial, is whether the Association of American Medical practitioners confront this issue the end product of an orthopaedic Colleges, Health Volunteers Overseas/Orthopaedics Overseas, every time a partner is added to the residency has changed and whether and the South Carolina Orthopaedic group or a new faculty member that change was intentional and for Association. joins the department. What should the better or misguided and with J Am Acad Orthop Surg 2017;25: established colleagues expect of a adverse consequences. If the end 416-420 new partner or faculty member product has changed, its current DOI: 10.5435/JAAOS-D-17-00240 entering practice after residency? status must be examined to deter- Some characteristics are intuitive; mine the remediable causes of any Copyright 2017 by the American Academy of Orthopaedic Surgeons. we know them when we see them, undesirable change, including the butwemayhaveahardtime role of the 80-hour work week.

416 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Vincent D. Pellegrini, Jr, MD

little to glean an introduction to care patient encounters, faculty surgeons The Changing Landscape of the surgical patient and general now personally perform more of Orthopaedic Residency surgical principles. patient interviews and assessments, Education The proliferation and formalization surgical procedures, and critical of orthopaedic subspecialties have documentation tasks (ie, dictating It is important to acknowledge that claimed focused instruction time, surgical notes) than they did pre- the work-hour guidelines imposed by which we call rotations, during the viously. Sanctions and financial the Accreditation Council for Gradu- orthopaedic residency program. A penalties can be imposed on teaching ate Medical Education (ACGME) are typical program with four residents hospitals for alleged double-dipping not the only change that has occurred per year often has nine thematically or by billing Medicare for services that over the past three decades in ortho- anatomically defined subspecialty were ostensibly covered by direct paedic residency education. This rotations: trauma, hand, shoulder/ and indirect subsidies of graduate change has not been a scientifically elbow, spine, adult reconstruction, medical education. Through annual designed experiment with all variables musculoskeletal oncology, pediatric compliance training and required but the one in question held constant. orthopaedics, sports medicine, and reports of plans to ensure appropri- Rather, it has been an iterative evolu- foot/ankle. Often an affiliated vet- ate resident supervision, faculty are tion with several moving parts. At erans’ hospital accounts for another constantly reminded of those sanc- least three other major shifts have had rotation, as does a local community tions and the need to participate as substantive effect on the outcome of hospital where practitioners have more actively in the care provided to orthopaedic residency as the imposi- their own subspecialty focus. There- patients to avoid improper billing for tion of the 80-hour work week. fore, up to 11 or 12 dedicated rota- professional services. The duration of formal general tions compete for the 54 months Each of these three major shifts has surgical education has dramatically of orthopaedic education that remain infringed at least as much as work- decreased from 24 months, with no after the 6 months of nonorthopaedic hour guidelines on medical education requirement of orthopaedic expo- rotations. Indeed, if each resident in a and the degree of independence that sure, to 12 months, to the current program with four residents per year trainees can be afforded as their abil- standard of 6 months, which can is optimally afforded two tours on ities to act and practice without direct include the required nonclinical each rotation, the orthopaedic rota- supervision increase during residency. month of surgical skills education, tions demand a total of 66 months In this context, the 80-hour work leaving a mere 5 months of clinical (11 rotations of 3 months each, times week may be characterized as “the general surgical graduate education. two tours per rotation), which straw that broke the camel’sback” This devolution of general surgical mathematically exceeds the time because it temporally followed these education has affected more than available in a contemporary 5-year other three changes in the landscape justthetimecommittedtoasurgical residency program. In this scenario, a of medical education. Thus, im- service; it has involved the quality resident may experience a given plementation of the ACGME’swork- and content of the surgical ex- subspecialty service only once before hour guidelines commonly, but perience on those rotations. Lapa- graduation. These circumstances perhaps unfairly, bears most of the roscopic and other minimally allow little time for repetition, and blame for the substantial compromise invasive approaches have dramati- hence refinement, of the skills needed in the independence of medical cally reduced the morbidity of sur- to diagnose conditions and perform trainees during residency that has gical procedures for patients, but surgical procedures that form the occurred since the 1980s. they have also reduced the opportu- basis of independent practice. nity for the intern to see and perform Finally, the constraints of the surgical procedures, learn surgical institutional professional billing Expected Characteristics of techniques, and develop surgical compliance office have required the the Graduating skills. Because intensive care training teaching physician to supervise Orthopaedic Resident persists (appropriately) as an essen- trainees more directly. This mandate tial component of preorthopaedic compromises the effective indepen- Before deciding whether the end graduate medical education, resi- dence that can be extended to capa- product of orthopaedic residency has dents often gain only 2 or 3 months ble residents as they progress in their changed, it is important to define our of surgical experience before com- residency training. Because of the expectations of the graduating ortho- mencement of formal orthopaedic regulations and rules that govern paedic resident. That characterization residency education. This is far too billing of services performed during has been the subject of considerable

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. A Perspective on the Effect of the 80-Hour Work Week discussion. A description of the end technical task and the choreography practice. Although this quality will product of an orthopaedic residency requires practice and repetition, not be fully mature in the graduating is not simply a regurgitation of the which has been eloquently articulated resident, the purpose of residency orthopaedic curriculum. Some, as the requirement of 10,000 hours of education is to provide sufficient including this author, would argue practice to master technical skills and experience to establish a baseline that defining the desired end product related performance.1,2 foundation for this essential balance. of an orthopaedic residency is more Confident, in the most modest sense Too much, or too little, confidence important than defining an all- of the term, refers to an essential or caution can be problematic. The inclusive and exhaustive curricu- quality of a surgeon. Although inap- goal of the faculty is to strike a lum that specifies what should be propriate confidence and boastful- middle ground characterized by taught during residency. This foun- ness must be avoided, a lack of balance of these two attributes in dational distinction of the task at conviction in the operating room is every newly minted practitioner. hand is important as we seek to arguably much worse. “Paralysis by Caring, in the end, is the essence of determine whether the outcome of analysis” has often been used to doctoring and the basis of altruism. orthopaedic residency education has describe a surgeon’s indecision that Without the human element of kind- changed over the past three decades. leads to a protracted procedure, often ness, no amount of clinical acumen or Overall, this author would charac- complicated by the morbidity asso- technical skill will make a person a terize the graduating orthopaedic ciated with long surgical times and good physician. The heart of a com- resident as possessing the attributes uncertain or imprecise technical acts. plete education in a caring profession, represented by five adjectives: com- Appropriate confidence reflects not such as medicine, is the development petent, confident, cautious, caring, only proficiency in the technical of the compassion and understanding and communicative. aspects of surgery, but also the cog- implicit in the capacity to relate to Competent is perhaps the first nitive processes that lead to accurate other people, share in their challenges description that comes to mind. The decisions in the operating room. and triumphs, and provide support in graduating resident is assumed to be a Although confidence in the ambula- times of need. Although some would capable and safe independent practi- tory clinic setting is important, the argue otherwise, caring can indeed be tioner within the specialty domain of negative implications of insecurity taught, and it can be developed during orthopaedics. This attribute requires and indecision in the operating room, the course of a residency. It is as the command of an adequate fund of where time and efficiency are asso- essential to a good physician as are knowledge and facility with the ciated with a substantial premium, the knowledge and skill previously technical skills expected and required are even more profound. A word of referenced. to perform tasks and procedures caution is appropriate. Because con- Communicative recognizes the need within the scope of orthopaedic fidence is a subjective and individual for the physician to effectively convey practice. The orthopaedic resident quality, we rely on self-assessment information to patients. Without this must master cognitive and technical for its evaluation. Physicians are well attribute, the mere existence of the domains to be considered competent known for overly positive self- knowledge necessary for treatment and ready to enter independent appraisal of their own skills, so we does not provide sufficient reassur- practice. Some might contend that are well advised to receive such ance or comfort for the patient, which surgical residents are tasked with evaluations with caution and a is essential for full and optimal mastery of a dual curriculum that healthy dose of critical review. recovery from illness or injury. requires great dedication and com- Cautious balances the aforemen- Moreover, patient satisfaction has mitment; they must learn both a craft tioned confidence needed to practice become an integral component of and a knowledge base. Moreover, a efficiently, safely, and in the patient’s every physician’s public assessment, surgical craft has cognitive and tech- best interest. Healthy skepticism and and good communication skills fre- nical components that must be introspection should be instilled into quently avert adverse legal action mastered for proficiency. Indeed, graduating residents so that they can despite the occurrence of a less than performing in the surgical theater can effectively question the obvious ideal outcome. Therefore, even in be effectively broken down into a without going to the extreme of the absence of an altruistic desire technical exercise and a well- second-guessing instances of good to communicate effectively with choreographed dance that allows judgment. This delicate balance of patients, a successful practitioner in the procedure to proceed efficiently confidence and caution results from today’s environment recognizes the from one task to another through to a process of continuous development pragmatic need for highly effective completion. Mastery of both the and evolution during a lifetime of communication skills.

418 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Vincent D. Pellegrini, Jr, MD

Both remain common among today’s skills ranging from the complex to Changing Attitudes Among resident applicants. However, an the basic, such as operating a power Residents awareness of the implicit sacrifices saw, not overdrilling past the far needed to concurrently achieve both cortex of a tubular bone, cutting a Orthopaedic residents have changed life balance and a wealth of experi- suture with the nondominant hand, over the last three decades, as have ence in training seems to be less tying a suture in a deep hole, and their training programs and the palpable in today’s residents than in opening a needle driver with the world in which we all practice medi- earlier generations. nondominant hand. All these tech- cine. The typical incoming ortho- The acquisition of a substantial nical tasks require practice, as sug- paedic resident is, by all indicators, knowledge base, in addition to the gested by the 10,000-hour doctrine. smarter and better rounded than obligation to master the technical This time commitment will undeni- ever. Many of today’s medical school skills of the surgical craft, requires an ably extend beyond the 80-hour graduates have been encouraged to element of practice that cognitive work week into personal time out- pursue a gap year after college, and psychologists have recognized as the side of work. Similarly, someone those selected for orthopaedic resi- 10,000-hour phenomenon.1 These desiring to perfect a recreational dency typically have higher United researchers have suggested that no tennis or golf game will spend hours States Medical Licensing Examina- matter how much intrinsic talent is hitting balls against a wall or on the tion scores than their faculty teachers inherited by the most fortunate and driving range. Yet, despite the pro- had when they were residents a few gifted of people, success in a technical liferation of surgical skills laborato- decades ago. Accordingly, matricu- profession or trade requires a requi- ries and simulation facilities in lating orthopaedic residents are site amount of structured and pur- today’s residency programs, most brighter, better rounded, and per- poseful practice. This requirement residents seem to rarely use those haps more grounded in the humane comes with no protected boundaries spaces beyond the time designated values desirable in a physician than around personal and work time. for structured curricular offerings. were their predecessors. However, Therefore, residents must accept an Finally, the work-hour guidelines this personal balance and intrinsic implicit sacrifice of personal time can be credited with the propensity intellect seem to have come at an outside of work to commit to learn- among residents to adopt a shift- undesirable cost that is increasingly ing and practicing the technical skills worker mentality. Because of the evident in the graduating orthopae- that are required to enter unsuper- need to comply with ACGME rules, dic residents of the current era. vised and independent orthopaedic we discipline residents who stay Several recent orthopaedic pro- practice after graduation. This sac- beyond their predefined work shift, gram applicants, likely motivated by rifice seems to be less evident in despite our desire that they would a strong desire for personal balance, today’s residents. At the least, the want to stay to provide continuity of have inquired about the relationship need to sacrifice one’s personal time care to their patients. We especially between faculty and residents in our has been made less clear to the cur- seek those qualities in our own phy- program and the opportunity for rent cadre of residents. sicians, and we expect, and hope, that residents to engage in outside pur- One calculation of the differential our residents will adopt a more suits. Applicants in previous genera- in work hours before and after the altruistic approach to the care of their tions surely considered such imposition of duty-hour guidelines patients after graduation, when the questions, but those thoughts were has suggested that today’s residents demands of patient care outweigh largely kept to oneself and certainly have lost the equivalent of 2 years of any limit to the work hours of prac- were never posed directly to the pro- 80-hour work weeks in training, ticing orthopaedic surgeons. Herein gram director or chair. This devel- compared with prior generations.3 lies perhaps the most troubling defi- opment can be largely attributed to This finding is evident in the reduced ciency directly attributable to generational differences rather than technical skill and surgical confi- ACGME work-hour guidelines; the effect of work-hour guidelines. dence of today’s graduating ortho- today’s graduating residents accept Yet, the expectation of life balance paedic residents, .95% of whom less ownership of the care of their and limited work hours accompanies now electively pursue an additional patients and do so less willingly. This the persistent and traditional desire to year of graduate medical education outcome remains a matter of specu- amass considerable surgical experi- in the form of a fellowship. A similar lation because no data are available ence during training and be granted state exists in general surgical resi- to compare the work hours of recent substantial independence to test one’s dency programs.4 Technical defi- graduates while in practice with their technical skills during residency. ciencies are evident in core surgical pregraduation work hours. The fear

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. A Perspective on the Effect of the 80-Hour Work Week of many medical educators is that graduate’s fitness for independent not add time to the overall education patients’ common expectation that practice after 6 years despite the need calendar, and decreases student debt their physician will be available for retention at the end of the tra- by reducing the years of tuition and whenever illness or injury strikes ditional 5 years of training. increasing the years of paid work may be misaligned with the expec- All would agree that the ultimate during residency. tation of work-hour limits that we end point of graduate medical edu- have inculcated in today’s graduat- cation is a defined level of pro- ing residents. ficiency deemed necessary to enter Summary unsupervised orthopaedic practice. Graduate medical education, partic- Many solutions to this dilemma will ularly in the surgical disciplines, is not be proposed, and at least two are A Moving End Point exempt from the concept of deliber- evident. We can alter expectations to ate practice being a prerequisite to The finished product of an ortho- accept the objective of preparing the achieving mastery of the skills and paedic residency has changed over graduate of an orthopaedic resi- competencies required for high- the past three decades, and the dency program for a fellowship year quality patient care. Amid the impo- imposition of an 80-hour work week in which skills will be refined to sition of the 80-hour work week and has undoubtedly contributed to this enable independent medical prac- other changes to the graduate medi- outcome. The realization that nearly tice. Alternatively, we can retain the cal education landscape, it has all graduating orthopaedic residents challenging goal of having the end become increasingly apparent that pursue additional formal medical product of an orthopaedic residency the surgical disciplines will need to education in the form of a fellowship beapractice-readygraduate.How- find new ways to enable residents to year invites the consideration of one ever,thislattergoalwillrequirean achieve 10,000 hours of deliberate final concept. Perhaps the goal of approach that supports more hours practice to ensure patient safety, no residency education has insidiously of orthopaedic education and train- matter how many calendar years are moved away from preparing the ing than are currently acquired required to reach that elusive but graduate to directly enter indepen- within the current 9-year frame- necessary goal.3 dent medical practice and has instead work of 4 years of medical school evolved to preparing the graduate for and a 5-year residency. The evolu- a fellowship year, in which surgical tion to true competency-based edu- References skills are refined and the ability to cation would require some trainees act independently is achieved. This to remain in a residency program for Evidence-based Medicine: Levels of weighty topic has far-reaching longer than the traditional 5 years to evidence are described in the table of implications and requires further attain the defined end points. Con- contents. In this article, reference 1 is discussion. The evidence suggests versely, the time in a residency a level I study. Reference 4 is a level that decreased hours in training over program might be reduced for III study. References 2 and 3 are level a defined 5-year residency period, in exceptionally gifted trainees. V expert opinion. concert with the other previously Considerations of escalating stu- References printed in bold type are cited substantial changes affecting dent debt and the anticipated physi- those published within the past 5 the process of resident education, cian shortage present sobering years. have resulted in a need for more cal- arguments against lengthening the endar years to reach the same end total duration of medical education 1. Ericsson KA, Krampe RT, Tesch-Romer C: The role of deliberate practice in the point. The author has personal and strong incentives to more effi- acquisition of expert performance. Psychol experience with retention of five res- ciently use the existing years dedi- Rev 1993;100(3):363-406. idents for a sixth year of training cated to training. One option that is 2. Colvin G: Talent Is Overrated: What Really before graduation over the past 12 gaining popularity is an accelerated Separates World-Class Performers From Everybody Else. New York, NY, Penguin years in programs of four and five transition to residency education in Group, 2008. residents per year. This retention rate which all or part of the fourth year of 3. Pellegrini VD Jr: Perspective: Ten thousand equates to only approximately 10% medical school is repurposed to hours to patient safety, sooner or later. Acad of the residents educated in those accommodate first-year postgraduate Med 2012;87(2):164-167. programs during that period. In each rotations after early graduation and 4. Mattar SG, Alseidi AA, Jones DB, et al: instance, the sixth-year graduate awarding of the MD degree. This General surgery residency inadequately prepares trainees for fellowship: Results of a was a solid, if not stellar, performer. arrangement provides increased survey of fellowship program directors. Ann No questions remained about the hours in residency education, does Surg 2013;258(3):440-449.

420 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.