High Efficiency Allows Plastic Surgery Trainees to Maintain Operative Experience Within the Limitations of an 80-Hour Work Week
Frank H. Lau, MD, Indranil Sinha, MD, Elof Eriksson, MD, PhD.
Brigham & Women's Hospital, Boston, MA, USA.
PURPOSE:Graduate medical education has undergone dramatic changes in the last 10 years. In the wake of these changes, time studies have been performed to quantify and examine the impact of these regulations on trainee experiences. These studies found that internal medicine trainees spend 12% of their time in direct patient care. Notably, these studies have focused exclusively on non-surgical trainees and the majority of such studies looked solely at interns.
We anticipate that quantitative, detailed data such as those produced by time studies will influence future changes in graduate medical education. It is therefore critically important that surgical trainees’ experiences be represented in the literature, and that this data encompass all levels of surgical training. We performed the first time study focusing exclusively on surgical trainees.
METHODS:We performed a descriptive, observational time study on an inpatient plastic surgery service at a large academic medical center in Boston, MA from August through October 2013. Each position on the team was followed for 10 days. Overnight call shifts were excluded.
RESULTS: 642.4 hours of data were collected over the course of the study. Participants included 7 plastic surgery residents and 1 intern of the general surgery residency program rotating on the inpatient plastic surgery service.
Trainees spent an average of 49.2% (range 34.6% to 61.7%) of their work hours in direct patient care. The largest category of direct patient care was surgery (mean 37.9% of weekly work hours, range 22.6% to 46.1%). More years of training correlated strongly with more time spent in direct patient care (R = 0.86). However, more years of training correlated weakly with more time spent in surgery (R = 0.501).
Trainees’ days were highly fragmented: the mean time spent per task was 11.6 minutes (range of means 7.6 minutes to 17.5 minutes). Overall, trainees were relatively efficient; however the mean time spent waiting for other clinical services (e.g. anesthesia, nursing staff) was 349.2 minutes per week (9.1% of the work week, range 230.5 to 521.7 minutes).
CONCLUSION: This is the largest time study of surgical trainees reported in the literature. Compared to internal medicine interns, plastic surgery trainees spend 189%-414% more time in direct patient care. Consistent with other studies comparing pre- and post-implementation of work hours, more years of training correlated strongly with more time spent in direct patient care. Time spent in surgery does not account for the majority of this increase. Because of the several-fold higher allocation of time to direct patient care, work hours limitations leave surgical trainees with less time for tasks such as documentation, administrative responsibilities, and education. Work hours limitations and ACGME requirements for surgical programs should reflect the inherently different nature of training in surgery compared to non-surgical fields.
Overall, plastic surgery trainees are efficient and effective at accomplishing a very wide variety of clinical tasks. Efficiency may be improved by reducing fragmentation of trainees’ workdays and by reducing the amount of time spent waiting on other clinical services. The re-gained time would best be allocated to trainee education.
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