Orthopaedic surgery residency has undergone many changes ranging from limitations on resident work hours and longer orthopaedic surgery rotations during the intern year, to increased documentation requirements for surgical and clinical "milestones."

These changes were implemented to improve patient care, provide better resident lifestyles, and reduce resident fatigue. But whether changes in hours and rotations have actually delivered on these claims is an ongoing debate.

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted an 80-hour work week, followed by a 16-hour daily work hour limit for interns in 2011. These rules were created to decrease the number of fatigue-related medical adverse events. Current evidence would suggest, however, that they may have failed to achieve this goal.

A comparison of mortality rates in more than 8 million Medicare patients admitted to short-term, acute-care, general hospitals found no significant increase or decrease in adverse events before and after the implementation of the 80-hour work week. Additional studies have confirmed these results in both medically and surgically treated patients.

The 10,000-hour rule
In his book Outliers, author Malcolm Gladwell discusses "the 10,000-hour rule." Essentially, he claims that it takes 10,000 hours of practice to achieve mastery in a field, citing examples of violin players, computer programmers, and elite athletes. Similarly, to master the field of orthopaedic surgery, practice is necessary. A physician cannot simply walk into the operating room and perform a perfect ulnar collateral ligament reconstruction or total knee arthroplasty without having prepared for, seen, and helped with a substantial number of these cases in the past.

However, the institution of the 80-hour work week may have severely limited the amount of practice orthopaedic surgery residents get. One study compared the surgical case experiences of PGY-2 and PGY-3 residents in a single program during the academic years 2002–2003 (just prior to the institution of the 80-hour work week) and 2003–2004 (the first year the 80-hour work week was in effect). Data from subjective questionnaires and objective ACGME case logs were analyzed. Under the 80-hour work week, residents performed 21.5 percent fewer cases overall and 20.44 percent fewer cases per rotation than they had previously.

Simulator training
One attempt to mitigate the effects of work-hour restrictions has been to increase the use of simulators. In theory, simulator training would enable orthopaedic surgery residents to refine their skills outside of the operating room, free from the limitations of the work-hour restrictions.

Whether the skills residents learn on simulators translate to improved outcomes for patients is still unclear. Multiple studies have shown that practice on simulators makes residents more proficient at performing specific tasks. More recent studies show transfer validity of simulator training to operating room efficiency, specifically in knee arthroscopy. Future studies looking at patient outcomes between orthopaedic surgery residents trained with simulators and those without simulator training will be beneficial.

Although simulator training is certainly a step in the right direction to help orthopaedic residents become proficient in surgery, a substitute for case experience has yet to be found. Unfortunately, work-hour limitations are not offset by decreases in administrative and other duties. On the contrary, administrative hours have increased, resulting in an even greater reduction in surgical time.

Effect on academic activity
Studies have shown that institution of an 80-hour work week has not affected average orthopaedic in-training exam scores for residents. Furthermore, the number of publications per resident—as well as the total number of resident publications—has increased, probably due to having more free time outside of clinical responsibilities. So, although clinical volume appears to have decreased, nonclinical activities may have increased commensurate with the increase in free time.

But, surgeons are not evaluated solely on their number of publications or their ability to perform well on a test. Surgeons are tasked with caring for real patients, and the decline in number of cases could lead to problems down the road. To compensate for time lost to work-hour restrictions, the ACGME changed the time spent on orthopaedic surgery rotations from 3 months to 6 months during the intern year and decreased the general surgery requirements to 3 months.

Although this change provides earlier exposure to orthopaedic surgery, it could have an adverse impact on medical management of patients; these interns may not gain adequate exposure to the perioperative and medical management of sicker and more complex patients. Orthopaedic surgery residents must be well-rounded doctors first, and orthopaedic surgeons second.

The fork in the road
With conflicting data on the impact of work-hour limitations, the question of how to adequately train orthopaedic residents remains unsolved. Among the proposed solutions are the following:

• Altering the 80-hour work-week requirement to enable residents to decide whether to limit themselves each week
• Extending the orthopaedic surgery residency program to a minimum of 6 clinical years (Although this would provide more training time, it would also increase the debt acquired and delay the start of a real job for many trainees.)
• Requiring residents to complete a minimum number of simulator training hours and instructional course hours prior to graduation
• Instituting a skills-based exam for residents, with tasks in each different specialty prior to graduation
• Advancing residents through training based on their mastery of surgical skills as opposed to duration of time spent training

It may be that no single "correct" answer exists, but these questions are worthy of debate and open for discussion. What is clear is that orthopaedic surgery training is at a crossroads, and the decisions made over the next few years will resonate for decades.

Brandon J. Erickson, MD, is a PGY-4 and Jeremy M. Burnham, MD, is a PGY-5 orthopaedic surgery resident.

References:

1. ACGME. Frequently Asked Questions: ACGME Common Duty Hour Requirements 2011 [cited 2015 November 18]. Available at https://www.acgme.org/acgmeweb/Portals/0/PDFs/dh-faqs2011.pdf. Accessed December 11, 2015.
2. Volpp KG, Rosen AK, Rosenbaum PR, et al: Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. JAMA 2007;298(9):975-983. Available at http://www.ncbi.nlm.nih.gov/pubmed/17785642. Accessed December 11, 2015.
3. Volpp KG, Rosen AK, Rosenbaum PR, et al: Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. JAMA 2007;298(9):984-992. Available at http://www.ncbi.nlm.nih.gov/pubmed/17785643. Accessed December 11, 2015.
4. Yaghoubian A, Kaji AH, Ishaque B, et al: Acute care surgery performed by sleep deprived residents: Are outcomes affected? J Surg Res 2010;163(2):192-196. doi: 10.1016/j.jss.2010.04.011. Epub 2010 May 6. Available at http://www.ncbi.nlm.nih.gov/pubmed/20655546. Accessed December 11, 2015.
5. Gladwell M. Outliers: The Story of Success. New York, NY, Little, Brown, 2008, pp. 309.
6. Aim F, Lonjon G, Hannouche D, Nizard R: Effectiveness of virtual reality training in orthopaedic surgery. Arthroscopy 2015 Sep 24. pii: S0749-8063(15)00648-9. doi: 10.1016/j.arthro.2015.07.023. [Epub ahead of print]. Available at http://www.ncbi.nlm.nih.gov/pubmed/26412672. Accessed December 11, 2015.
7. Dunn JC, Belmont PJ, Lanzi J, et al: Arthroscopic shoulder surgical simulation training curriculum: Transfer reliability and maintenance of skill over time. J Surg Educ 2015;72(6):1118-1123. doi: 10.1016/j.jsurg.2015.06.021. Epub 2015 Aug 19. Available at http://www.ncbi.nlm.nih.gov/pubmed/26298520. Accessed December 11, 2015.
8. Cannon WD, Garrett WE Jr, Hunter RE, et al: Improving residency training in arthroscopic knee surgery with use of a virtual-reality simulator. A randomized blinded study. J Bone Joint Surg 2014;96(21):1798-1806. doi: 10.2106/JBJS.N.00058. Available at http://www.ncbi.nlm.nih.gov/pubmed/25378507. Accessed December 11, 2015.
9. Weatherby BA, Rudd JN, Ervin TB, Stafford PR, Norris BL: The effect of resident work hour regulations on orthopaedic surgical education. J Surg Orthop Advances 2007;16(1):19-22. Available at http://www.ncbi.nlm.nih.gov/pubmed/17371642. Accessed on December 11, 2015.
10. Froelich J, Milbrandt JC, Allan DG: Impact of the 80-hour workweek on surgical exposure and national in-training examination scores in an orthopedic residency program. J Surg Educ 2009;66(2):85-88. Available at http://www.ncbi.nlm.nih.gov/pubmed/19486871.  Accessed December 11, 2015.
11. Namdari S, Baldwin KD, Weinraub B, Mehta S: Changes in the number of resident publications after inception of the 80-hour work week. Clin Orthop Relat Res 2010;468(8):2278-2283. Available at http://www.ncbi.nlm.nih.gov/pubmed/20155407. Accessed December 11, 2015.
12. ACGME: ACGME Program Requirements for Graduate Medical Education in Orthopaedic Surgery 2015 [cited 2015 November 18]. Available at  https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/260_orthopaedic_surgery_2016.pdf. Accessed December 11, 2015.