Restricted Duty Research Articles

Physical Therapy Intervention for a Patient With Post-Surgical Shoulder Capsulorrhaphy

Background: Posterior shoulder capsulorrhaphy is a surgical procedure to help restore shoulder joint stability in patients with a history of recurrent shoulder dislocations. Physical therapy (PT) may be beneficial in outpatient rehabilitation to improve patient shoulder range of motion (ROM), muscular strength, endurance, joint stability, and return to prior level of activities after general shoulder surgery. The purpose of this case study was to describe PT intervention for a patient with shoulder posterior capsulorrhaphy in an outpatient setting. Methods: 21-year-old male with post-surgical right shoulder posterior capsulorrhaphy due to multiple posteriorshoulder dislocation. Patient’s impairments were right shoulder weakness, decreased ROM, and functional immobility due to pain and a retracted capsule. PT intervention was 2-3X per week for nine weeks and included therapeutic exercises, manual therapy, modalities, and patient education for a home exercise program (HEP). Results: Patient was seen for 13 visits in an outpatient PT setting which improved his shoulder active ROM, strength, and outcome measures. The pain was also reduced. He returned to work with light duty restrictions after the 3rd week of PT and was able to perform normal responsibilities by the 9th week. He achieved the majority of his goals. Conclusion: PT intervention may have accelerated the progression of patient’s functional mobility, strength, ROM, and reduction of pain. Compared to the currently available literature for this diagnosis, the patient returned to normal function three weeks earlier than normal, probably due to earlier internal rotation exercise. Future research should include a randomized control trial regarding effective PT interventions following shoulder capsulorrhaphy surgery.

Health- and Performance-Related Outcomes in Air Force Medical Service Personnel with a Post-Deployment Mental Health Condition.

This study examined associations between incident post-deployment mental health (PDMH) conditions and health- and performance-related outcomes in the population of Air Force Medical Service personnel on active duty between 2003 and 2013 who had at least one deployment. Using a posttest-only with nonequivalent groups design, the study cohort was divided into two groups based on the occurrence of an incident PDMH condition, and the groups were then compared in terms of the following health- and performance-related outcomes: health care and pharmaceutical utilization, duty and mobility restrictions, and physical fitness assessment exemptions and composite fitness score. Archival data were extracted from existing databases and associations were assessed using both parametric and nonparametric approaches. The cohort comprised 12,216 participants, from which subcohorts were drawn to assess specific outcome measures. Participants with an incident PDMH used health care at 1.8 times the rate and were 6.2 times more likely to be classified as a high utilizer of health care as compared with those without a PDMH condition (controls). They were 2.1-103.0 times more likely to be prescribed one of 22 therapeutic classes of medication and were 2.4 times more likely to have polypharmacy than controls. They were 2.5 times more likely to have a duty or mobility restriction, and the ratio of days spent with a restriction to days without a restriction was 1.8 times that of controls. Lastly, they were 2.4 times more likely to have a physical fitness assessment exemption, but there was no significant difference in the likelihood of a composite fitness score of <90 points. The presence of an incident PDMH condition was associated with increased health care and pharmaceutical utilization and decreased occupational performance as assessed in terms of restricted duty status and participation in physical fitness assessments.

Occupational Outcomes of Reconstructive Surgery for Adult Acquired Flatfoot Deformity.

Reconstruction of a symptomatic adult flatfoot is an involved operation with a long recovery period. No previous studies have looked at the occupational or functional results of athletically active patients who have undergone this surgery. In the U.S. Military, the rates of return to unrestricted active duty are unknown. A retrospective review of all active duty military patients who underwent a reconstructive surgery for adult acquired flatfoot surgery at a single institution from January 2001 to 2015 was performed. 50 patients met inclusion criteria. 28 of 50 patients (56%) remained on active duty with permanent duty restrictions, and only 2 of 50 patients (4%) returned to full duty without restrictions. 20 of 50 (40%) patients underwent a Medical Evaluation Board to separate from the military. A difference was noted in terms of the hindfoot realignment procedure performed: the probability of a Medical Evaluation Board is higher for those patients who had a lateral column lengthening procedure as compared to those who were treated with a medializing calcaneal osteotomy. The sample size is the largest study to date of young active patients who underwent surgical correction for symptomatic pes planus. The results demonstrate that a service member with symptomatic pes planus requiring surgery faces a 96% chance of failure to return to his or her preinjury level of function. Although some patients (56%) were able to remain on active duty with restrictions, there is a 40% chance that service members will face separation from the military because their foot pain despite a year of surgery and recovery. Furthermore, patients treated with a lateral column lengthening had a higher probability of being medically discharged than those who had a medializing calcaneal osteotomy.

Outcomes of Lisfranc Injuries in an Active Duty Military Population

Category: Midfoot/Forefoot, Sports, Trauma Introduction/Purpose: Traumatic injuries to the tarsometatarsal or Lisfranc joints can be complex problems associated with long-term pain, disability, and deformity. Most current literature advises early open reduction and internal fixation (ORIF) for acute Lisfranc injuries and reserves arthrodesis for chronic injuries, isolated ligamentous injuries, or salvage procedures. There is also a reported association between delayed diagnosis or missed injuries and poor outcomes. The purpose of this study was to evaluate the association between time from injury to treatment and method of fixation with outcome. Methods: A retrospective review of 171 non-battle related closed tarsometatarsal dislocations and fracture dislocations was conducted of patients identified using the Department of Defense Trauma Registry and Military Health System Mart from 2009- 2014 searching by CPT codes. Demographic information, injury characteristics, treatment course, and physical evaluation board results were examined. Return to duty was defined as a patient returning to full duty and passing their service specific physical fitness test. We excluded polytrauma patients, battle injuries, deep infections requiring surgical debridement, those with pre- existing duty limiting conditions, those who separated from the military for unrelated reasons prior to completing their rehabilitation and those with incomplete data. Results: Overall of 107 patients 69% returned to full active duty, 4% returned to limited duty with permanent duty restrictions and 27% underwent a medical evaluation board and were ultimately discharged from service. The ORIF group consisted of 80 patients; the average time from injury to fixation was 2.5 weeks and 63% returned to full duty, 6% returned on permanent profile. Of the arthrodesis group 20 underwent primary arthrodesis with an average time from injury of 15.4 weeks and a return to duty rate of 80%. Seventy-one percent of patients who underwent arthrodesis as a salvage procedure for failed ORIF or post-traumatic osteoarthritis (PTOA) underwent a medical evaluation board and were discharged from service. Conclusion: This represents one of the largest cohorts in the literature and redemonstrates that tarsometatarsal dislocations and fracture-dislocations are serious injuries that can lead to permanent disability. The data also demonstrates very low return to duty rates in those who underwent salvage arthrodesis reinforcing the importance of initial anatomic reduction and the poor outcomes of PTOA. Most notably it demonstrates higher return to duty rates among patients who underwent primary arthrodesis despite the inclusion of more missed/chronic injuries when compared to ORIF. This suggests that primary arthrodesis may be a viable option in a young and active population despite later treatment.

Occupational Outcomes Of Reconstructive Surgery For Adult Acquired Flatfoot Deformity

Category: Hindfoot Introduction/Purpose: Reconstruction of a symptomatic adult flatfoot is an involved operation with a long recovery period. No previous studies have looked at the occupational or functional results of athletically active patients who have undergone this surgery. In the United States military, the rates of return to unrestricted active duty are unknown. Methods: A retrospective review of all active duty military patients who underwent a reconstructive surgery for adult acquired flatfoot surgery at a single institution from January 2001-2015 was performed. Surgical, inpatient, and outpatient databases were searched via CPT and ICD9 codes. Approximately 1300 cases with potential flatfoot reconstructive surgery were identified. Only those patients with the diagnosis of flatfoot treated with both a boney procedure and a soft tissue procedure were included. Patients had to have at least one year follow-up or follow-up to the point of maximum medical benefit as defined by the operative provider. Final disposition of the patients had to have been recorded in the medical record. Three possible outcomes were utilized in the review of this cohort: patient returned to duty without restrictions, patient returned to active duty with restrictions, or patient separated from active duty due all or in part to this medical condition. Results: Fifty patients met inclusion criteria. 30/50 patients (60%) remained on active duty with permanent duty restrictions, and only two of 50 patients (4%) returned to full duty without restrictions. 20/50 (40%) underwent a Medical Evaluation Board (MEB) to separate from the military. A difference was noted in terms of the hindfoot realignment procedure performed: the probability of an MEB is higher for those patients who had a lateral column lengthening procedure than those who were treated with a medializing calcaneal osteotomy. Conclusion: The sample size is the largest study to date of patients with surgical correction for symptomatic pes planus. The results demonstrate that a service member with symptomatic pes planus requiring surgery faces a 96% chance of failure to return to pre-injury level of function. While some (60%) were able to remain on active duty with restrictions, there is a 40% chance that service members will face separation from the military due to their foot pain. Furthermore, patients treated with a lateral column lengthening had a higher probability of being medically discharged than those who had a medializing calcaneal osteotomy.

Free Flap Reconstruction Monitoring Techniques and Frequency in the Era of Restricted Resident Work Hours

ImportanceFree flap reconstruction of the head and neck is routinely performed with success rates around 94% to 99% at most institutions. Despite experience and meticulous technique, there is a small but recognized risk of partial or total flap loss in the postoperative setting. Historically, most microvascular surgeons involve resident house staff in flap monitoring protocols, and programs relied heavily on in-house resident physicians to assure timely intervention for compromised flaps. In 2003, the Accreditation Council for Graduate Medical Education mandated the reduction in the hours a resident could work within a given week. At many institutions this new era of restricted resident duty hours reshaped the protocols used for flap monitoring to adapt to a system with reduced resident labor.ObjectivesTo characterize various techniques and frequencies of free flap monitoring by nurses and resident physicians; and to determine if adapted resident monitoring frequency is associated with flap compromise and outcome.Design, Setting, and ParticipantsThis multi-institutional retrospective review included patients undergoing free flap reconstruction to the head and/or neck between January 2005 and January 2015. Consecutive patients were included from different academic institutions or tertiary referral centers to reflect evolving practices.Main Outcomes and MeasuresTechnique, frequency, and personnel for flap monitoring; flap complications; and flap success.ResultsOverall, 1085 patients (343 women [32%] and 742 men [78%]) from 9 institutions were included. Most patients were placed in the intensive care unit postoperatively (n = 790 [73%]), while the remaining were placed in intermediate care (n = 201 [19%]) or in the surgical ward (n = 94 [7%]). Nurses monitored flaps every hour (q1h) for all patients. Frequency of resident monitoring varied, with 635 patients monitored every 4 hours (q4h), 146 monitored every 8 hours (q8h), and 304 monitored every 12 hours (q12h). Monitoring techniques included physical examination (n = 949 [87%]), handheld external Doppler sonography (n = 739 [68%]), implanted Doppler sonography (n = 333 [31%]), and needle stick (n = 349 [32%]); 105 patients (10%) demonstrated flap compromise, prompting return to the operating room in 96 patients. Of these 96 patients, 46 had complete flap salvage, 22 had partial loss, and 37 had complete loss. The frequency of resident flap checks did not affect the total flap loss rate (q4h, 25 patients [4%]; q8h, 8 patients [6%]; and q12h, 8 patients [3%]). Flap salvage rates for compromised flaps were not statistically different.Conclusions and RelevanceAcademic centers rely primarily on q1h flap checks by intensive care unit nurses using physical examination and Doppler sonography. Reduced resident monitoring frequency did not alter flap salvage nor flap outcome. These findings suggest that institutions may successfully monitor free flaps with decreased resident burden.

Personal Digital Assistant-Based Self-Work Sampling Study of Pediatric Interns Quantifies Workday and Educational Value

ObjectiveOptimizing clinical proficiency and education of residents has become more important with restricted residency duty hours. Our objective was to investigate how interns spend their time on inpatient rotations and the perceived educational value of workday activities. MethodsWe performed a descriptive self-work sampling study using a personal digital assistant (PDA) to randomly query interns on inpatient rotations in real time regarding their activity and the perceived educational value of that activity on a 4-point Likert scale. ResultsA total of 31 interns participated on 88 workdays over a 5-month period, generating 2082 samples from which the average workday was modeled. Time spent using the electronic health record (EHR) accounted for 33% of intern time, communicating with the health care team 23%, educational activities 17%, and time with patients and families 12%. Time with patients and families was perceived to be the most educational part of clinical service. Time spent using the EHR was perceived as the least educational. Interns perceived clinical service as excellent or good 37% of the time, while planned educational activities were perceived as excellent or good 81% of the time. ConclusionsInterns spend the majority of their time using the EHR and communicating with the health care team. Interns perceive time spent in planned educational activities has more educational value than time spent in clinical service. The distribution of daily activities is discordant with the perceived educational value of those activities.

Winter Deployment 14 and 15: an audit of injury and illness rates in an Arctic environment

Arduous military training in a cold weather environment is likely to lead to a variety of injuries to the population at risk (PAR). This paper examines injury rates and medical presentations over the two years of Winter Deployments in 2014 and 2015 (WD14 and WD15) and proposes recommendations for future WDs. Data on injury rates, number of aeromedical evacuations, and number of days of restricted duties allocated were collected prospectively for all patients presenting to Asegarden Medical Centre, Norway, during WD14 and WD15. The data were calculated as a percentage of the total PAR on each deployment to allow meaningful comparison. During WD14, 22.8% of the PAR presented to the Medical Centre compared to 26.9% during WD15. WD15 saw a reduction in the presentation of musculoskeletal (MSK) injuries, cold weather (CW) injuries and burns. Skin problems and diarrhoea and vomiting (D&V) remained similar in both years. An increase in dental and other presentations was seen in WD15. A reduction in the overall aeromedical evacuations and number of patients requiring a light duties (LD) chit was seen during WD15. WD15 has seen a decrease in injury rates, the number of aeromedical evacuations and LD chits issued. It is difficult to know whether these changes are a result of improved medical support, training or equipment. The liaison between the command, medical and training elements has led to improvements and should now concentrate on ways to further reduce injury rates whilst maximising arduous training benefits in an Arctic environment.

Exploring Qualitative Perspectives on Surgical Resident Training, Well-Being, and Patient Care

The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial found no difference in patient outcomes or resident well-being between more restrictive and flexible duty hour policies. Qualitative methods are appropriate for better understanding the experience and perceptions of those affected by duty hour regulations. We conducted a pilot qualitative study on how resident duty hour regulations are perceived by general surgery program directors, surgical residents, and attending surgeons who participated in the FIRST Trial. Semi-structured qualitative interviews were pilot tested with program directors, residents, and attendings to examine initial perceptions of the standard and flexible policies implemented during the trial. The transcribed interviews were analyzed thematically using a constant comparative approach and grouped first by study arm and then by level (patient, surgeon, program, and national). More restrictive duty hours were perceived as creating a tension between resident personal and professional well-being. Standard Policy resulted in more transitions, which was perceived as creating vulnerable gaps in patient care. Standard Policy restrictions were seen as particularly challenging for interns and often led to inadequate preparation for promotion and encouraged a shift mentality. In our pilot study, interviewees valued the flexibility afforded in the Flexible Policy arm, as it allowed them to maximize patient safety and educational attainment. Additional qualitative research will expand on program director, resident, and attending perceptions of resident duty hours as well as perceptions of patient safety. Qualitative methods can contribute to the national debate on resident duty hours.

Screening for depression in the occupational health setting.

The cost of workplace absenteeism and presenteeism due to depression in the USA is substantial. To assess the frequency of depression and its impact at the point of care in an occupational health (OH) practice. Patients presenting to an OH practice completed a standardized depression screening tool and were compared to an unscreened group in the same clinic. Respondents with a nine-item Patient Health Questionnaire (PHQ-9) score >15 and untreated for depression were referred for further evaluation per usual practice. A comparison group of unscreened patients were selected from the same clinic from 1 year prior and records were reviewed for evidence of prior depression, treatment and outcomes. After 1 year, frequency of depression, PHQ-9 scoring for screened patients, days absent from work, days on restricted duties and permanent restrictions were recorded for both groups. Two hundred and five patients were screened for depression. Screening was associated with increased frequency of a diagnosis of current depression (30 versus 4%; P < 0.05). Screening was associated with similar rates of absenteeism but lower number of days on restricted duties (97 versus 159 days; P < 0.001). After adjusting for age, sex, history of and treatment for depression, screening was associated with lower odds of being on work restrictions [odds ratio (OR) 0.55; 95% confidence interval (CI) 0.38-0.78] or permanent restrictions (OR 0.35; 95% CI 0.23-0.52). Depression was common in this OH practice. Screening for depression, with appropriate recognition and referral, may reduce time for employed patients on restricted duties and permanent restrictions.

Curriculum reform for residency training: competence, change, and opportunities for leadership.

Certain pressures stemming from within the medical community and from society in general, such as the need for increased accountability in resident training and restricted resident duty hours, have prompted a re-examination of methods for training physicians. Leaders in medical education in North America and around the world champion competency-based medical education (CBME) as a solution. The Department of Anesthesiology at the University of Ottawa launched Canada's first CBME program for anesthesiology residents on July 1, 2015. In this paper, we discuss the opportunities and challenges associated with CBME and delineate the elements of the new CBME program at the University of Ottawa. Review of the current literature. Competency-based medical education addresses some of the challenges associated with physician training, such as ensuring that specialists are competent in all key areas and reducing training costs. In principle, competency-based medical education can better meet the needs of patients, providers, and other stakeholders in the healthcare system, but its success will depend on support from all involved. As CBME is implemented, anesthesiologists have the opportunity to become leaders in innovation and medical education. The University of Ottawa has implemented a CBME program with a twofold purpose, namely, to focus learning opportunities on the development of the specific competencies required of practicing anesthesiologists and to test the effectiveness of a reduction in the length of training. Canadian anesthesia residency programs will soon transition to CBME in order to promote better transparency, accountability, fairness, fiscal responsibility, and patient safety. Competency-based medical education offers significant potential advantages for healthcare stakeholders.

Determinants of between-year burrow re-occupation in a colony of the European bee-eater Merops apiaster.

Re-occupation of existing nesting burrows in the European bee-eater Merops apiaster has only rarely – and if so mostly anecdotically – been documented in the literature record, although such behavior would substantially save time and energy. In this study, we quantify burrow re-occupation in a German colony over a period of eleven years and identify ecological variables determining reuse probability. Of 179 recorded broods, 54% took place in a reused burrow and the overall probability that one of 75 individually recognized burrows would be reused in a given subsequent year was estimated as 26.4%. This indicates that between-year burrow reuse is a common behavior in the study colony which contrasts with findings from studies in other colonies. Furthermore, burrow re-occupation probability declined highly significantly with increasing age of the breeding wall. Statistical separation of within- and between-burrow effects of the age of the breeding wall revealed that a decline in re-occupation probability with individual burrow age was responsible for this and not a selective disappearance of burrows with high re-occupation probability over time. Limited duty cycles of individual burrows may be caused by accumulating detritus or decreasing stability with increasing burrow age. Alternatively, burrow fidelity may presuppose pair fidelity which may also explain the observed restricted burrow reuse duty cycles. A consequent next step would be to extend our within-colony approach to other colonies and compare the ecological circumstances under which bee-eaters reuse breeding burrows.

Agricultural Occupational Health and Safety Perspectives Among Latino-American Youth

ABSTRACTAgricultural work is one of the most dangerous jobs for adolescents. Through a university-community partnership, the authors surveyed young primarily acculturated Latino-American farmworkers 14 to 18 years of age regarding their agricultural work experience. Topics included occupational health and safety education, work history, and information sources. The authors also evaluated the Rapid Clinical Assessment Tool (RCAT), a pictorial tool for identifying agricultural tasks to enhance discussion with clinical providers. One hundred forty youth with farmwork experience completed the survey; 6% reported a previous work-related injury or illness and 53% reported receiving some workplace health and safety training. Correct identification of legally restricted duties for youth varied but were generally low: participants identified working alone past 8 pm (57%), driving a forklift (56%), doing roofing work (39%), working in freezers (34%), and driving a delivery vehicle (30%). The Internet was identified as the most likely and reliable place youth would go to find information on workplace health and safety. Few (15%) reported clinician-initiated conversations on occupational health; however, a high proportion responded positively to questions regarding the usefulness of the RCAT for this purpose. This study highlights the need for workplace health and safety guidance for youth employed in agriculture. The results support Internet-based outreach and use of the RCAT to help facilitate occupational health discussions in clinical settings.

English

Residents are physicians undertaking further training to become independently licensed practitioners. Historically, resident duty hour periods were long and intense. The goal was to maximize learning through high patient volume and to teach doctors how to take responsibility. Recently, concerns over patient and resident safety have led to restricted trainee work hours. The putative justification is to improve resident education, resident well-being, and patient care. In light of this recent shift in the medical culture, resident duty hours have become a controversial topic. Restricted duty hours take many forms. In the United States, the Accreditation Council for Graduate Medical Education (ACGME) mandated junior residents work no longer than 16 consecutive hours, while senior residents could work up to 26 hours.1 In Canada, no nationwide mandate exists and the issue falls within provincial jurisdiction. In Ontario, under the Professional Association of Residents of Ontario agreement, call-periods are no more than 26 consecutive hours in-house, no more than one in four nights in-house, or no more than one in three nights of home-call. After a 2011 Quebec court ruling, resident duty hours were restricted to 16 consecutive hours in that province. This resulted from the court concluding that traditional hours violate the Canadian Charter of Rights and Freedoms. Regardless, the Quebec ruling prompted other Canadian programs to further reduce resident duty hours and consecutive hours on-call. To better understand this complex issue, the following review discusses resident safety, resident performance, resident education, and patient safety. Our goal is to present a balanced, evidence-based discussion, addressing both patient safety and resident fatigue management.

Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance.

In 2011, the Accreditation Council for Graduate Medical Education (ACGME) restricted resident duty hour requirements beyond those established in 2003, leading to concerns about the effects on patient care and resident training. To determine if the 2011 ACGME duty hour reform was associated with a change in general surgery patient outcomes or in resident examination performance. Quasi-experimental study of general surgery patient outcomes 2 years before (academic years 2009-2010) and after (academic years 2012-2013) the 2011 duty hour reform. Teaching and nonteaching hospitals were compared using a difference-in-differences approach adjusted for procedural mix, patient comorbidities, and time trends. Teaching hospitals were defined based on the proportion of cases at which residents were present intraoperatively. Patients were those undergoing surgery at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). General surgery resident performance on the annual in-training, written board, and oral board examinations was assessed for this same period. National implementation of revised resident duty hour requirements on July 1, 2011, in all ACGME accredited residency programs. Primary outcome was a composite of death or serious morbidity; secondary outcomes were other postoperative complications and resident examination performance. In the main analysis, 204,641 patients were identified from 23 teaching (n = 102,525) and 31 nonteaching (n = 102,116) hospitals. The unadjusted rate of death or serious morbidity improved during the study period in both teaching (11.6% [95% CI, 11.3%-12.0%] to 9.4% [95% CI, 9.1%-9.8%], P < .001) and nonteaching hospitals (8.7% [95% CI, 8.3%-9.0%] to 7.1% [95% CI, 6.8%-7.5%], P < .001). In adjusted analyses, the 2011 ACGME duty hour reform was not associated with a significant change in death or serious morbidity in either postreform year 1 (OR, 1.12; 95% CI, 0.98-1.28) or postreform year 2 (OR, 1.00; 95% CI, 0.86-1.17) or when both postreform years were combined (OR, 1.06; 95% CI, 0.93-1.20). There was no association between duty hour reform and any other postoperative adverse outcome. Mean (SD) in-training examination scores did not significantly change from 2010 to 2013 for first-year residents (499.7 [ 85.2] to 500.5 [84.2], P = .99), for residents from other postgraduate years, or for first-time examinees taking the written or oral board examinations during this period. Implementation of the 2011 ACGME duty hour reform was not associated with a change in general surgery patient outcomes or differences in resident examination performance. The implications of these findings should be considered when evaluating the merit of the 2011 ACGME duty hour reform and revising related policies in the future.

Board #205 - Program Innovation The Pediatric Critical Care Boot Camp

ObjectivesPediatric critical care (PCC) fellows are expected to perform in a high-pressure, high-risk environment right after residency, where restrictive duty hours are believed to limit clinical/procedural exposure. 1-4 Simulation-based training (SBT) affords educators in this field the opportunit

Training for the future NHS: training junior doctors in the United Kingdom within the 48-hour European working time directive.

Since August 2009, the National Health Service of the United Kingdom has faced the challenge of delivering training for junior doctors within a 48-hour working week, as stipulated by the European Working Time Directive and legislated in the UK by the Working Time Regulations 1998. Since that time, widespread concern has been expressed about the impact of restricted duty hours on the quality of postgraduate medical training in the UK, particularly in the “craft” specialties – that is, those disciplines in which trainees develop practical skills that are best learned through direct experience with patients. At the same time, specialist training in the UK has experienced considerable change since 2007 with the introduction of competency-based specialty curricula, workplace-based assessment, and the annual review of competency progression. The challenges presented by the reduction of duty hours include increased pressure on doctors-in-training to provide service during evening and overnight hours, reduced interaction with supervisors, and reduced opportunities for learning. This paper explores these challenges and proposes potential responses with respect to the reorganization of training and service provision.

Return to duty after elective fasciotomy for chronic exertional compartment syndrome.

Civilian literature has reported excellent outcomes after elective fasciotomy for chronic exertional compartment syndrome (CECS). Our study's purpose was to objectively investigate the functional outcome of fasciotomies performed for CECS in a high demand military population. A retrospective review of all fasciotomies performed for CECS at a single tertiary military medical center was performed. The primary outcome measure was the ability to return to full active duty. Diagnosis, operative technique, and number of compartments addressed were collected and analyzed. Patients were contacted and the visual analog scale (VAS) pain score, functional single assessment numeric evaluation (SANE) score, as well as overall satisfaction were reported. Return to duty status was collected on 70 of 70 (100%) consecutive operative extremities in 46 patients with an average follow-up of 26 months. Only 19 patients (41.3%) were able to return to full active duty. Ten patients (21.7%) underwent a medical separation from the military and 17 patients (37%) remained in the military but were on restricted duty secondary to persistent leg pain. Thirty-five of 46 (76%) of the patients were contacted and provided subjective feedback. The average SANE score was 72.3, and there was a mean improvement of 4.4 points in VAS score postoperatively. Overall, 71% of patients were satisfied and would undergo the procedure again. Outcomes were correlated to operative technique, patient rank, and branch of military service. Our study showed a return to full military duty in 41% of patients who underwent elective fasciotomy for CECS. Overall 78% of patients remained in the military, which is consistent with previous military literature. Subjective satisfaction rate was 71%. Both the return to activity and subjective outcomes in our study population were substantially lower than reported results in civilian populations. Level IV, case series.

High-Intensity Cardiac Rehabilitation Training of a Firefighter After Placement of an Implantable Cardioverter-Defibrillator

Firefighters who have received an implantable cardioverter-defibrillator (ICD) are asked to retire or are permanently placed on restricted duty because of concerns about their being incapacitated by an ICD shock during a fire emergency. We present the case of a 40-year-old firefighter who, after surviving sudden cardiac arrest and undergoing ICD implantation, sought to demonstrate his fitness for active duty by completing a high-intensity, occupation-specific cardiac rehabilitation training program. The report details the exercise training, ICD monitoring, and stress testing that he underwent. During the post-training treadmill stress test in firefighter turnout gear, the patient reached a functional capacity of 17 metabolic equivalents (METs), exceeding the 12-MET level required for his occupation. He had no ICD shock therapy or recurrent sustained arrhythmias during stress testing or at any time during his cardiac rehabilitation stay. By presenting this case, we hope to stimulate further discussion about firefighters who have an ICD, can meet the functional capacity requirements of their occupation, and want to return to work.

Survey of internal medicine physicians trained in three different eras: reflections on duty-hour reform.

To survey internal medicine physicians and residents who have completed residency in three different eras of medical training regarding their experiences during their intern year and their perceptions of duty-hour reform. An online survey was administered to 268 residents, fellows, and staff physicians who had completed or were completing residency during one of three eras of training: before the 80-hour work week, after the 80-hour work week (instituted in 2003), and after the 16-hour limit on continuous shifts for interns (instituted in 2011). The survey assessed experiences during their intern year of residency and perceptions regarding resident duty-hour reform. The majority of respondents (n = 32; 54%) indicated that duty-hour restrictions would result in residents being less prepared for their future careers. In addition, 36% (n = 21) of respondents anticipated a decrease in the quality of patient care under the restricted duty hours. A total of 41% (n = 24) were undecided regarding the impact of duty-hour reform on patient care. Respondents reported time spent on independent study, research, and conference attendance did not increase following the institution of duty-hour restrictions. Survey responses indicated that after 18 months of experience with the Accreditation Council for Graduate Medical Education duty-hour restrictions, physician opinions were mixed and a substantial number remain undecided regarding the impact of duty-hour restrictions on resident career preparedness and the quality of patient care.