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through scholarly publication and demonstration of successful leadership. They
also discovered that many physicians who took part in efforts to improve resident
education or overall quality of care rated their overall professional satisfaction to
be improved. Academic surgeons are both responsible for patient care and resi-
dent education. Therefore, clinician educators in academic surgical departments
are uniquely positioned to address both institutional and system-wide improve-
ments in QI/PS.
Challenges
Resident Factors
A major challenge in implementing meaningful and sustainable quality improve-
ment measures is the natural turnover of trainees in surgical residency programs [ 4 ,
14 ]. The rapid pace and transient nature of residency training, combined with time
demands, can result in a lack of ownership over the residency program or patients
[ 4 ]. Well-established units may be resistant to changes proposed by a trainee who is
“passing through” [ 14 ]. To address these problems, some residency programs have
established team-based approaches in which resident groups take over projects from
previous groups to ensure continuity and increase the likelihood of completion [ 2 ].
In addition, timing of resident involvement in research in general and let alone long-
term QI/PS projects can be challenging. While some residency programs offer dedi-
cated research time, many residencies do not offer protected time or “light rotations”
to ensure residents have sufficient time outside of work responsibilities to dedicate
to projects [ 8 ]. These programs may rely more heavily on didactics to deliver QI/
PS-related information to residents.
Work hours have been targeted as a reason for decreased resident effectiveness,
although the data supporting this is unclear. Dating back to the Libby Zion case in
which a woman died while being treated by a fatigued resident, resident work hours
have remained a point of contention [ 33 ]. While some suggest that unlimited work
hours lead to more errors, others cite that restrictions in work hours result in an
overall negative impact because of increased handoffs. The results of the FIRST
trial were published in February 2016 and showed no difference in outcomes in resi-
dents with less restrictive duty hour policies compared with those with restricted
duty hours [ 34 ]. In addition, there were no differences in resident dissatisfaction or
quality of education. That being said, residents with flexible duty hour policies may
have less time available to complete research and/or QI/PS projects.
Some have suggested that there is seasonal variation in the quality of patient care
related to the “July effect” when new residents start each year [ 35 ]. The literature is
somewhat inconsistent on this matter, but some sources suggest that operating room
efficiency is decreased and overall mortality may be increased in early training
months. Other sources suggest that resident involvement, in general, may have a
negative impact on patients no matter what time of year [ 36 , 37 ]. These results
showed that resident involvement increased overall length of stay and decreased OR
efficiency but that overall patient care was not affected.
E.L. Ferguson and C.P. Sundaram