1. Operative Volume in the New Era: A Comparison of Total Resident Operative Volume Pre vs. Post 80-Hour Work Week Restriction Implementation Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D. Department of Surgery, The University of Kansas School of Medicine-Wichita Wichita, Kansas

2. ACGME 2003 Duty Hour Restrictions In-house call no more than every third night One day off per week (averaged over 4 weeks) 24-hour limit (6-hour extension) 10 hours off between shifts <80 work week average

3. Impact on operative experience Jarman 2004-projected losses of 100- 200 cases Mendoza 2005-10-25% reductions predicted by general surgery program directors

4. Studies Showing Stable Operative Volume Bland 2005- no difference in total or chief resident volume Ferguson 2005- no change in total operative volume and an increase in chief resident operative volume Schneider 2007-increase in operative volume totals, especially for PGY1&2’s

5. Studies Showing Negative Impact on Operative Volume Carlin et al. 2007- significant decrease in operative volume for PGY1, 2, and 4 residents and a decrease in first assist and teaching assist volume Damadi et al. 2007- overall decrease in both chief and total operative cases Kairys 2008-10% of residents at risk for not meeting the 750 total case requirement

6. No previous published study has evaluated operative volume of general surgery residents who completed their entire residency after implementation of work-hour restrictions

7. Study Objective Determine the impact of the duty hour restrictions (DHR) on general surgery resident operative volume in a general surgery residency program over the course of an entire “DHR” residency

8. Methods IRB-approved retrospective review Final operative logs of graduated general surgery residents University of Kansas-Wichita -6 residents per year Control group:2001, 2002, 2003 Study group: 2008, 2009 19 ACGME Defined Categories Operative Volumes Non-operative trauma excluded, leaving 18 categories for comparison

9. Results Operative volumes in 12/18 defined categories were not significantly affected Operative volume in 1/ 18 defined categories (Laparoscopic- Basic) was positively affected Operative volumes in 4/18 defined categories were negatively affected Head/Neck Trauma Thoracic Plastics

10. Results Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D. Department of Surgery, The University of Kansas School of Medicine-Wichita Wichita, Kansas Before Duty Hour RestrictionAfter Duty Hour Restrictions 2001, 2002, 20032008, 2009 Number of Chief ResidentsMinimum RRC Requirements1712P Value Head and Neck2579.766.50.0326 * Skin/ Soft Tissue/ Breast245054.70.3785 Alimentary Tract72119.5122.30.7852 Abdomen65165.8192.50.0536 Liver48.5100.3651 Pancreas36.46.60.8062 Vascular44159.4140.80.2741 Endocrine833.837.40.2319 Trauma- Operative1026.213.50.0002 * Trauma- Non operative20---41.1--- Thoracic1545.432.50.0164 * Pediatrics2027.231.40.1268 Plastics520.113.80.0301 * Endoscopy85269.8250.80.5644 Laparoscopic- Basic60166.2231.30.0001 * Laparoscopic- Complex2560.767.50.2921 Teaching Cases---15.99.50.1418 TOTAL CHIEF CASES150268.7253.20.4278 TOTAL MAJOR CASES750119311090.2719

11. Results Program changes made to accommodate DHR Night float system PGY3 and PGY1 residents Trauma service changes Cessation of resident coverage at 1 of the 2 level I trauma centers in the community with care provided subsequently by attendings and physician extenders Team concept of trauma coverage with two teams (PGY 2/4, PGY2/5) covering alternating 24 hour periods for 2 month rotations

12. Discussion Trauma-number of cases decreased by 52% (26 to 13) Deletion of resident coverage at one Level I Trauma Center, substantially decreasing the amount of trauma call taken by residents over the course of the training program Increasing role of non-operative management for the care of trauma patients

13. Discussion Head/Neck – number of cases decreased by 16% (79 to 66) Majority of cases recorded in this category were tracheostomies of which the majority are performed on the trauma rotation

14. Discussion Thoracic - number of cases decreased by 28% (45 to 32) Decrease in number of months on the cardiothoracic rotation from 6 to 2 Migration of cases to a specialty heart hospital

15. Discussion Plastics - number of cases decreased by 31% (20 to 13) No major change in the educational structure of the plastic surgery experience Decrease may be a factor of an anomaly of interest in plastic surgery in the control group Migration of cases to outpatient facilities

16. Discussion Limitations Single institutional study of case volume involving a limited number of residents Operative volumes and duty hours are self-reported Confounding factors affecting case totals other than duty hours Defined categories do not fully reflect complexity of operative experience

17. Conclusions Resident operative volume at our institution’s general surgery residency program has been largely unaffected by implementation of the 80-hour work week Residencies in general surgery can be structured in a manner to allow for compliance with duty hour regulations while maintaining the required operative volume as outlined by the ACGME defined categories