Resident Hours Research Articles

The effect of poor sleep and occupational demands on driving safety in medical residents

ABSTRACTObjective: The Accreditation Council for Graduate Medical Examination recently revised and implemented duty hour standards that increased maximum duty hours for first-year medical residents and reduced the minimal amount of time off between duty periods for all medical residents. Little work has examined driving performance of medical residents at multiple periods surrounding duty, including in reference to off-duty driving performance as a baseline. Certain work-related factors that may be negatively impacted in medical residents, such as sleep quality, fatigue, and stress, are known to affect mental and physical performance and may further exacerbate driving risks. The overall objective of this study was to examine driving performance of medical residents off duty, preduty, and postduty using a high-fidelity driving simulator.Method: Thirty-two medical residents were enrolled and wore sleep tracking devices over several days. Both self-reported and objective estimates of sleep quality, fatigue, and stress were collected at off-duty, preduty, and postduty points of time. The medical residents drove in a high-fidelity driving simulator at each time point to provide objective driving performance metrics.Results: Findings indicated that medical residents experienced the highest levels of stress and sleep propensity preduty and displayed riskier driving behaviors postduty. Those further into their residency were less affected by the negative effect of stress on driving performance, and those with better sleep quality metrics were also less affected by the negative effects of increased stress on driving outcomes.Conclusions: The impact of occupational demands on psychophysiological outcomes requires further investigation to better understand the mechanisms of how work demands affect these psychophysiological outcomes. Understanding how to mitigate high job strain may have several implications in improving psychophysiological functions impacted by occupational demands, namely, sleep quality and stress, and subsequently improving driving safety outcomes that may also be negatively affected by the duty demands.

A Formal Work Hour Analysis of the Resident Foot and Ankle Surgeon

As new documentation requirements by governments and third-party payees increasingly occupy physicians' time, duty hour restrictions have continued to restrict the work hours of residents, leaving programs tasked to produce proficient foot and ankle surgeons (FASs) in less time. The purpose of the present study was to quantify the workday of resident FASs at our institution to identify areas suited for revision to improve efficiency and training. A resident from each postgraduate year (PGY) was recruited and consented for minute-to-minute observation by 4 independent observers over 5 consecutive workdays. The time recorded was placed into a predefined work model consisting of 9 categories (education, research, operating room, patient care, documentation/administration, communications, transit, basic needs, and standby) within 1 of 3 value groups (positive, neutral, or negative). A fifth independent observer reviewed and recorded all collected data. Over 5 consecutive days, ancillary staff frequently disrupted the PGY-1 resident's workflow. The interruptions fragmented the resident's thoughts, increased inefficiency, and resulted in the largest proportion of the resident's time (16.7%) being occupied by documentation/administration duties. For the PGY-2 and PGY-3 residents, unexpected trends in standby were identified during the preoperative period. Secondary analysis revealed that during unexpected preoperative delays, resident efficiency was poor. To maximize efficiency and improve training, residents must increase their awareness of self-inefficiency while minimizing unnecessary interruptions and the time occupied by duties of lesser value. It is our hope that the present study will aid other institutions in facilitating similar improvements to the education and training of our fellow resident FASs.

Impact of Resident Overnight Duty Hour Changes on Obstetrical Outcomes: A Population-Based Cohort Study.

To determine whether obstetrical patient outcomes have changed following the introduction of restricted resident work hours. A population-based retrospective cohort study of the effects of restricted duty hours for residents in July 2013 at three academic hospitals in Toronto, ON using linked health care databases. The study included 6763 deliveries in the 2 years pre-exposure and 5548 deliveries in the 2 years post-exposure. The primary outcome, planned prior to data collection, was a composite index of 29 maternal/fetal outcomes including maternal transfusion/postpartum hemorrhage, maternal infection, fetal mortality, NICU admissions, and surgical/obstetrical complications. There were seven secondary outcomes analysed: NICU admissions; neonatal death; maternal transfusion or postpartum hemorrhage; maternal infection; and three composite measures. A generalized estimating equation model, clustered by institution, was utilized to assess for differences post-intervention. We found no significant differences in baseline demographics between groups. After the implementation of duty hour restrictions, no significant difference was seen in the primary outcome. However, an increased incidence of composite maternal surgical/obstetrical outcomes (OR 1.191; 95% CI 1.037-1.367, P = 0.013) and transfusion/postpartum hemorrhage (OR 1.232; 95% CI 1.074-1.413, P = 0.003) was found. There were no significant differences in other secondary outcomes. Since the implementation of resident duty hour restrictions, there was no overall change in patient outcomes. However, there was an increase in surgical/obstetrical complications and transfusion/postpartum hemorrhage. This suggests that duty hour restrictions may not be beneficial to patient outcomes. It highlights the need to further investigate the clinical impact of a change in resident duty hours.

AIR TRANSPORT ACCESSIBILITY AND TRANSPORT DISCRIMINATION OF POPULATION IN CONSTITUENTS OF THE RUSSIAN FEDERATION

The article deals with the introduction of numerical indicators for the notions "the air transport accessibility" and "the transport discrimination of the population" as applied to the local (suburban) traffic. Due to significant financial cost of air service, the local airlines are essential only in those regions of the Russian Federation, where the low-cost ground traffic is impossible. Thereby, the air transport accessibility should be considered as paired accessibility "the regional center - the capital of the constituent of the Russian Federation". This fact imposes restrictions on those indicators that can be applied to the relevant numerical estimates. A technique has been developed for numerical estimation of transport accessibility and transport discrimination of the population using the notions "transport accessibility levels" and "minimum social transport standard". The results of calculations with a software package based on geoinformation system are presented. It is shown that when using only the ground transport, the capital transport accessibility level of the constituent of the Russian Federation exceeds four hours for residents including more than 450 municipal and urban districts in 50 constituents of the Russian Federation. The most of these territorial entities belong to the hard-to-reach territories of Northwestern, Ural, Siberian and Far Eastern Federal Districts of Russia. The total population of these entities is about 15 million people, which is more than 10% of the total population of Russia. The existing local airlines can solve the transportation problems in local traffic for about 5 million people. To ensure four-hour level of transport accessibility for the rest of the population, it is necessary to organize at least 300 local airlines in the constituents of the Russian Federation.

Outcomes in microvascular head and neck reconstruction in the setting of restricted residency hours

BackgroundResident duty hour restrictions can limit the frequency of resident flap checks at smaller institutions with “home” call. Institutions are compensating with adjuvant nursing flap checks as well as incorporating technology; however, this management remains controversial. MethodsA prospective cohort of 122 free flaps for reconstruction of the head and neck by a single surgeon. Demographic information, operative details, postoperative care, and flap outcomes were recorded. ResultsOver 42 months, 122 free flaps were performed on 115 patients. The overall flap success rate was 96%. The flap success rate at 72 h was 98% and 96% at the time of discharge with reexploration rates of 11.6%. The intraoperative and postoperative salvage rates were 71% and 64.3% respectively. ConclusionLimited resident flap checks combined hourly nurse flap checks and an implantable Doppler is an effective monitoring protocol for academic programs in the setting of residency duty hour restrictions.

Validation of a Full-Immersion Simulation Platform for Percutaneous Nephrolithotomy Using Three-Dimensional Printing Technology.

The restriction of resident hours with an increasing focus on patient safety and a reduced caseload has impacted surgical training. A complex and complication prone procedure such as percutaneous nephrolithotomy (PCNL) with a steep learning curve may create an unsafe environment for hands-on resident training. In this study, we validate a high fidelity, inanimate PCNL model within a full-immersion simulation environment. Anatomically correct models of the human pelvicaliceal system, kidney, and relevant adjacent structures were created using polyvinyl alcohol hydrogels and three-dimensional-printed injection molds. All steps of a PCNL were simulated including percutaneous renal access, nephroscopy, and lithotripsy. Five experts (>100 caseload) and 10 novices (<20 caseload) from both urology (full procedure) and interventional radiology (access only) departments completed the simulation. Face and content validity were calculated using model ratings for similarity to the real procedure and usefulness as a training tool. Differences in performance among groups with various levels of experience using clinically relevant procedural metrics were used to calculate construct validity. The model was determined to have an excellent face and content validity with an average score of 4.5/5.0 and 4.6/5.0, respectively. There were significant differences between novice and expert operative metrics including mean fluoroscopy time, the number of percutaneous access attempts, and number of times the needle was repositioned. Experts achieved better stone clearance with fewer procedural complications. We demonstrated the face, content, and construct validity of an inanimate, full task trainer for PCNL. Construct validity between experts and novices was demonstrated using incorporated procedural metrics, which permitted the accurate assessment of performance. While hands-on training under supervision remains an integral part of any residency, this full-immersion simulation provides a comprehensive tool for surgical skills development and evaluation before hands-on exposure.

Improving Communication Through Resident-Nurse Shadowing.

Previously, reduced resident hours, multiple ways to communicate (text paging, calling), and fewer opportunities for face-to-face communication had led to increased frustration from residents and nurses in our institution about communicating and prioritizing patient care needs. It was thought that a shared understanding and improved teamwork and communication between residents and nurses might be achieved if the residents could watch the nurses' workflow and observe their care priorities. To understand the experience of residents and nurses who had participated in a novel 4-hour nurse shadowing experience conducted during the first year of pediatric medical residency in a children's hospital. We undertook a basic interpretive qualitative study by using semistructured interviews to formally evaluate the shadowing program by examining the experiences of both the first-year residents and the nurses being shadowed. Residents and nurses who had participated in the past 3 years were eligible for inclusion in the study. Seven themes emerged that supported the overarching theme of improving communication between residents and nurses. Shadowing led to improved resident understanding and appreciation of nurses' work. Both residents and nurses experienced enhanced relationships as they discussed opportunities to improve care delivery. Residents reported practice changes after shadowing a nurse. Peer relationships formed among the dyads that extended beyond the shadowing experience. Shadowing a nurse proved to be a valuable experience that had an impact on participants and potentially a positive impact on patient care.

Internal Medicine Residency Program in Iran: Exclusive Features and an International Comparison

Background: Internal Medicine (IM) is one of the main medical specialties. In this paper, the features of the Iranian IM residency training program, duties and salary were evaluated and compared with some countries. Methods: Using the Iranian Ministry of Health and Medical Education (IMHME) directive, the features of educational curriculum, compulsory working hours, duties and salary were extracted and compared with some countries whose full details were available. Results: The annual capacity of IM residency admission in Iran is about 280 residents in 34 countrywide medical universities. The training curriculum of IM is designed uniformly for all universities by IMHME and is consisted of a 4-year training of gastroenterology, endocrinology, nephrology, pulmonary, hematology and rheumatology plus cardiology, neurology, intensive care, emergency medicine, radiology and dermatology in hospital departments and continuity clinics. Residency training period in Iran is similar to Turkey and Canada and is shorter than most European countries. Average weekly working hours for IM residents is 84 hours in Iran, which is higher than Turkey European countries, Canada and the USA. Two to eight years of medical service in underserved areas have been assigned for Iranian graduates of IM residency before receiving certification for working in larger cities. Conclusion: Residency training in each country is affected by different factors such as economic status, work force, national health priorities and available facilities. Training of residents with more knowledge and skills that did not bear remarkable job burnout during their training period is a challenging goal for medical education policymakers

Working hour preferences of female and male residents : Developments over 4years of postgraduate medical training in Germany

This article addresses developments regarding working hours and working hour preferences of residents undergoing postgraduate training in Germany and analyses if, and for what reasons, full-time or part-time working models are preferred. The source of data is the KarMed study, which is based on yearly postal surveys carried out among graduates of the year 2008/2009 from seven medical faculties in Germany. The interviews took place during the entire postgraduate training period. Response rates were 48% in the first year, with subsequent rates of above 85%. For analysis, descriptive statistics and regression models were applied. There is aconsiderable discrepancy between the actual and the preferred working hours of residents undergoing postgraduate training. Postgraduate training is mostly linked to full-time contracts, usually with additional overtime, even though a considerable proportion of doctors prefer apart-time position. More female residents want to work part-time than male doctors. The same applies for the period after medical specialism: in particular, female doctors with children, female doctors trained in former Western Germany states, and those seeking an occupation in outpatient care request part-time contracts for their professional future. Asimilar trend has been increasingly observed over the years for male doctors. Despite the huge number of residents requesting part-time contracts - during postgraduate training and afterward - the reality is still far behind this model. It is apparent that measures should be taken for both genders. Those measures should facilitate the implementation of the favored working-time model.

Supplementing Intensivist Staffing With Nurse Practitioners: Literature Review.

In the United States, providing health care to critically ill patients is a challenge. An increase in patients older than 65 years, a decrease in critical care physicians, and a decrease in work hours for residents cause intensivist staffing issues. In this article, use of nurse practictioners to fill the intensive care unit intensivist staffing gap is assessed and evidence-based recommendations are identified to better incorporate nurse practitioners as part of intensive care unit intensivist staffing. The literature reveals that when nurse practitioners are part of a staffing model, outcomes are either positively impacted or no different from physician outcomes. However, successfully integrating nurse practitioners into an intensive care unit team is not adequately discussed in the literature. This gap is addressed and 3 mechanisms to integrate nurse practitioners into the intensive care unit are identified: (1) use of a multidisciplinary staffing model, (2) completion of onboarding programs, and (3) evaluation of nurse practitioner productivity.

What Is Known: Examining the Empirical Literature in Resident Work Hours Using 30 Influential Articles.

Examining influential, highly cited articles can show the advancement of knowledge about the effect of resident physicians' long work hours, as well as the benefits and drawbacks of work hour limits. A narrative review of 30 articles, selected for their contribution to the literature, explored outcomes of interest in the research on work hours-including patient safety, learning, and resident well-being. Articles were selected from a comprehensive review. Citation volume, quality, and contribution to the evolving thinking on work hours and to the Accreditation Council for Graduate Medical Education standards were assessed. Duty hour limits are supported by the scientific literature, particularly limits on weekly hours and reducing the frequency of overnight call. The literature shows declining hours and call frequency over 4 decades of study, although the impact on patient safety, learning, and resident well-being is not clear. The review highlighted limitations of the scientific literature on resident hours, including small samples and reduced generalizability for intervention studies, and the inability to rule out confounders in large studies using administrative data. Key areas remain underinvestigated, and accepted methodology is challenged when assessing the impact of interventions on the multiple outcomes of interest. The influential literature, while showing the beneficial effect of work hour limits, does not answer all questions of interest in determining optimal limits on resident hours. Future research should use methods that permit a broader, collective examination of the multiple, often competing attributes of the learning environment that collectively promote patient safety and resident learning and well-being.

Evidence-Based Review and Discussion Points.

Across acute care settings, acute care nurse practitioners (ACNPs) provide care to acutely and critically ill patients. In accordance with reductions in residency hours for physicians, there has been a proportional growth in the numbers of ACNPs who are needed to provide health care to high acuity patients. Despite the prevalence of ACNPs, there has been limited exploration into how this cohort of advanced practice nurses are credentialed or privileged to perform invasive procedures.To gain insight on how credentialing and privileging of ACNPs occur across hospitals statewide, the authors contacted all of the hospitals in California. Medical credentialing coordinators were interviewed by telephone and asked 7 questions that included hospital and ACNP demographic characteristics, a description of the credentialing and privileging processes, as well as details on the invasive procedures performed by ACNPs.In total, the authors were able to gather data from 74% (n = 246) of all the hospitals in California. Of these participating hospitals, fewer than half (48%) employed ACNPs and the majority (60%) of hospitals that privileged ACNPs for invasive procedures were teaching hospitals. The results of this study highlight that credentialing and privileging of ACNPs for invasive procedures typically involves proctored observations by a supervising physician and the number of proctored observations varies by hospital and procedure.Fatmata Jalloh, acnp-bc, cns, ccrn, lead author on this EBR article provides additional information about the study. She says that the study was designed to answer the prevailing question, “How are ACNPs credentialed and privileged to perform invasive procedures across hospitals in California?”According to Jalloh, this study grew out of need to understand the best practices for credentialing and privileging ACNPs who are expected to perform invasive procedures on acutely or critically ill patients. “We were the first group of nurse practitioners at our hospital that requested the privilege of performing invasive procedures and the medical credentialing coordinator had difficulty deciding on what was needed to privilege an ACNP to independently perform these procedures,“ she says.Jalloh points out that initially calls were made to affiliate hospitals about the credentialing and privileging processes for ACNPs. However, the lack of standardization among these hospitals prompted her and coauthors to conduct a statewide investigation to gain insight on variations in the credentialing and privileging process among hospitals across California.Jalloh encourages readers of the American Journal of Critical Care to consider the quality and safety implications that result from a lack of standardization of the credentialing and privileging processes. She hopes that her research sheds light on the inconsistencies in the credentialing and privileging processes for ACNPs and highlights the urgency for an evidence-based framework to standardize these processes, which may enhance the quality of patient outcomes.The study findings confirm that credentialing and privileging ACNPs to perform invasive procedures varies by hospital and type of invasive procedure. Jalloh explains that it is important for standardization of credentialing and privileging process for ACNPs and other advanced practice nurses performing invasive procedures. “Doing an invasive procedure a couple of times does not necessarily make an ACNP proficient at performing the procedure,” she adds.This feature briefly describes the personal journey and background story of the EBR article’s investigators, discussing the circumstances that led them to undertake the line of inquiry represented in the research article featured in this issue.Fatmata Jalloh, acnp-bc, cns, ccrn, is an acute care nurse practitioner at the Keck Medical Center of the University of Southern California in Los Angeles, California. She has been a registered nurse for more than a decade and is a board-certified advanced practice nurse who specializes in cardiology, internal medicine, and critical care.This project grew out of a need to identify how local hospitals credentialed and privileged ACNPs to perform invasive procedures. “We subsequently decided to publish our work because we thought it might be useful to other advanced practice nurses and hospital administrators,” comments Jalloh. She notes that her research received an unanticipated positive response from several of the medical credentialing coordinators who were genuinely interested in using the results to inform modifications to their credentialing and privileging processes.Regarding challenges faced during research, Jalloh says, “The main lesson that I learned was to identify your team members at the beginning of the project rather than bringing them on board after initiating the study.” She says collaboration with advanced practice nurses, a graduate nursing student, a trauma surgery fellow, and her medical director provided the requisite clinical and research expertise to successfully carry out the study procedures and generate the data needed to answer her research question.

Level of hopelessness and related factors in upcoming medical work force

Background and purpose: Students in medical schools are under the great personal distress during their education. Likewise, medical or surgical residency can be a stressful and overwhelming period during which residents work long hours. The aim of the study was to determine the level of hopelessness in the medical students and residents and to examine its relations with socio-demographic features and working conditions. Methods: A cross-sectional survey was conducted among 203 medical students and 132 medical residents in Pamukkale University, Turkey. Beck Hopelessness Scale (BHS) was used to measure the level of hopelessness. Results: Women constituted 49.3% of the participants. 20.3% of the participants were younger than 20. 35.2% of the participants were in the lowest SES. The mean BHS score was 5.76±4.5. The score in medical residents (7.29±5.1) was higher than in the 1 st (4.48±3.6), 3 rd (4.13±3.4) and 6 th grade medical students (5.4±4.1), (p 40-≤60 hours’, 6.1±4.4; ‘between >60-≤100 hours’, 7.97±5.6; and ‘over 100 hours’, 9.67±5.6, (p=0.028). Multivariate analysis showed that weekly working hours of the residents was the most important factor affecting the score (p<0.001). Conclusions: The hopelessness level of the medical residents was the highest and weekly working hours was the main factor affecting the hopelessness levels in the medical residents. Keywords: medical education; hopelessness; depression; students; residents.

The Impact of the 2011 Accreditation Council for Graduate Medical Education Duty Hour Reform on Quality and Safety in Trauma Care

In 2011, the ACGME limited duty hours for residents. Although studies evaluating the 2011 policy have not shown improvements in general measures of morbidity or mortality, these outcomes might not reflect changes in specialty-specific practice patterns and secondary quality measures. All trauma admissions from July 2009 through June 2013 at an academic Level I trauma center were evaluated for 5 primary outcomes (eg, mortality and length of stay), and 10 secondary quality measures and practice patterns (eg, operating room [OR] visits). All variables were compared before and after the reform (July 1, 2011). Piecewise regression was used to study temporal trends in quality. There were 11,740 admissions studied. The reform was not strongly associated with changes in any primary outcomes except length of stay (7.98 to 7.36 days; p= 0.01). However, many secondary quality metrics changed. The total number of OR and bedside procedures peradmission (6.72 to 7.34; p < 0.001) and OR visits per admission (0.76 to 0.91; p<0.001) were higher in the post-reform group, representing an additional 9,559 procedures and 1,584 OR visits. Use of minor bedside procedures, such as laboratory and imaging studies, increased most significantly. Although most major outcomes were unaffected, quality of care might have changed after the reform. Indeed, a consistent change in resource use patterns was manifested by substantial post-reform increases in measures such as bedside procedures and OR visits. No secondary quality measures exhibited improvements strongly associated with the reform. Several factors, including attending oversight, might have insulated major outcomes from change. Our findings show that some less-commonly studied quality metrics related to costs of care changed after the 2011 reform at our institution.

Integration of advanced practice providers into the Israeli healthcare system.

Many countries around the world have integrated various types of Advanced Practice Providers (APPs) into their healthcare systems. The main motivating factors for recognizing and developing APPs worldwide include physician shortages and the need for improved access or delivery (US, France, Belgium, Scotland, Switzerland), reduced residency hours (US, UK), shortages in underserved regions (US, Canada, Finland, Australia), and cost containment (Germany, Netherlands, UK, US).Israel is experiencing a shortage of physicians in peripheral geographic regions and in critical medical specialties. Recent by-laws approved by the Knesset (Parliament), combined with Israel Ministry of Health (MOH) policies, have thus far been unable to fully address the shortages. To understand the potential contribution of APPs in Israel, we evaluated the international historical foundations and development of APP roles. We assessed how APPs have impacted healthcare in other countries by analyzing public data and published international research about APP education, safety, quality of care, motivators, barriers, and impact. We found that APPs are recognized in dozens of countries, and have similar scopes of practice, graduate level education requirements (in developed countries), and clinical training.At the same time, there is wide variability among countries in the actual function and independence of the advanced practice nurse (APN), particularly the nurse practitioner (NP). APPs have been established as cost effective, safe healthcare providers who improve healthcare access.Israel has begun to introduce APPs, specifically NPs, in a variety of fields, including geriatrics, palliative care and diabetic care. We recommend a rapid expansion of existing and new APP roles into the Israeli healthcare system based on evidence and the recommendations of international evaluations by non-government organizations. By shifting the education to a university setting, mirroring successful, evidence-based, and established APP models found internationally, Israel could lessen the projected Israeli physician shortage, improve healthcare access in specific areas, and bolster existing resources towards a larger and richer pool of healthcare providers in Israel.

Cognitive and Psychomotor Function Changes Among Anesthesiology Residents After 12 Working Hours in Elective Anesthesia Service.

Background:The practice of anesthesia requires good awareness, parallel decision-making and fine motor skills. The duration of working hours of anesthesiology residents is often more than 12 hours.Objectives:This study aimed to measure cognitive and psychomotor functions of anesthesiology residents after 12 working hours.Patients and Methods:This was an observational study on anesthesiology residents who underwent 12 working hours. Each subject, who fulfilled inclusion and exclusion criteria, had their cognitive and psychomotor functions tested at 0 and 12 hours. The cognitive function was measured by “Cognitive Stimulation” test, while the psychomotor function was measured by the grooved pegboard. Statistical analysis was conducted to compare the results between 0 and 12 hours.Results:Cognitive Stimulation” test revealed statistically significant decrease at sequential image frequency stimulation (P = 0.035). Other stimulation tests did not show any statistically significant result. Grooved pegboard test showed statistically significant decrease in psychomotor function from 0 to 12 hours (P = 0.037).Conclusions:There was a decrease in cognitive function, including attention, visual memory, naming, and executive function, as well as psychomotor function among residents of Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia, who underwent 12 working hours.

Will the year 2016 augur well for better patient safety and health of residents in Korea according to the enactment of the Act for improving the resident training environment and enhancing resident's status?

Will the year 2016 augur well for better patient safety and health of residents in Korea according to the enactment of the Act for improving the resident training environment and enhancing resident's status?

The Impact of Resident Duty Hour and Supervision Changes: A Review.

In 2003 and again in 2011, the Accreditation Council for Graduate Medical Education (ACGME) instituted increasingly stringent requirements governing resident hours and supervision, with the goals of improving patient safety, resident well-being, and resident education. Although the changes initially stemmed from a catastrophic outcome in a patient treated with psychotropic medications and behavioral restraints, and have been in place over a decade, many psychiatrists are not familiar with these changes and with their potential effects and "side effects" on today's trainees and faculty. The authors review the history leading to these changes, summarize the revised requirements, and review representative literature regarding the impact of the changes. The existing studies of the impact of the new requirements on improving patient safety, resident well-being, and resident education are inconclusive, and most editorials, perspectives, and surveys of faculty and residents reflect a lack of enthusiasm for the changes. They go on to suggest the need for evidence-based outcome studies prior to the institution of further major changes in ACGME requirements.

Investigation of awareness with respect to hospitalist based on questionnaire by surgical residents and fellows in a single center

Purpose: Although the hospitalist which was first defined in USA at 1996 has been incorporated into a clinical activity in South Korea, adequate role of hospitalist is not established yet especially in the department of surgery. It is evident that the role of surgical residents or fellows are most influenced by the introduction of surgical hospitalist. However, the expectations of surgical residents or fellows on the role of the hospitalist has not been evaluated. Methods: This study was based on the questionnaire from surgical residents and fellows working at a single large center. Results: A total of 64 responders participated in this study. Most of the responders believe that certificate of internal medicine or family medicine is fit for the hospitalist. Most of the responders believe the obligatory limitation law of working hours for residents has not been kept well. The main reasons are overloading of working of residents or sustained operation schedules. They think that nurse practitioners or physical assistants may be of a help in partially, but, could not fully compensate for the work loading of residents. The most expected role of surgical hospitalist by residents or fellows is to replace the role of duty especially at night. The willingness to apply for surgical hospitalist after cessation of the training is low. This observation may suggest the concern of current uncertain surgical hospitalist’s role. Conclusion: This study demonstrates that the most expected role for surgical hospitalist by surgical residents and fellows is to replace the duty of night time.

Free flap monitoring: a review of the recent literature.

Free flap surgery has revolutionized our ability to perform composite reconstructions following ablative surgery. Although flap failure is rare (∼5%), it results in high patient morbidity if not recognized and corrected early. There are numerous means to assess flap viability. We review the recent literature on flap monitoring, and discuss the difference between techniques in regard to overall flap survival, cost, and ease of use. The current literature on implantable Doppler, microdialysis, video-based application (Eulerian), fluorescence angiography, spectroscopy, contrast-enhanced duplex, and activated clotting time is reviewed. Of these methods, implantable Doppler and spectroscopy have the most recent and largest series of data describing efficacy with implantable Doppler, demonstrating comparable flap survival rates to clinical monitoring. Arterial implantable Doppler has the additional benefit of less false-positives than venous Doppler. Spectroscopy demonstrates promise with commensurate flap survival rates and improved salvage rates over clinical monitoring. Clinical monitoring alone has proven to be so effective that it is difficult to demonstrate better outcomes with alternative methods. That said, a minimally invasive, reliable method that does not require physician assessment on a frequent basis would prove ideal in many small centers and academic centers limited by resident hours. Venous and, more recently, arterial monitoring have been successfully implemented at many programs. Spectroscopy appears promising, but the data are still limited.