171Repercussions of the 80-Hour Era
Following the implementation of the 2003 ACGME work-hour restrictions, numer-
ous studies were published on the theme of duty-hour restrictions. Compliance with
the new duty-hour requirement was found to be lacking. With the restriction of resi-
dent work hours, it was felt by some that surgical residents were graduating with
less surgical experience and familiarity with specific surgical procedures. Fonseca
and coworkers reported that graduating chief residents lacked appropriate confi-
dence in elements of vascular surgery and flexible endoscopy [ 30 – 32 ]. The level of
confidence seemed to relate to program size, case volume, and geography, among
other things. Additional work from the same group also suggested that a laparo-
scopic intensive training program also diminished confidence in open surgical pro-
cedures. Other studies have disputed this finding and noted that the majority of chief
residents were comfortable to go directly into practice, especially if they graduated
with more than 950 cases during their residency [ 33 ]. Additionally, 80% felt com-
fortable being on call at a level I trauma center. Procedures that engendered the most
discomfort included bile duct explorations, pancreaticoduodenectomies, hepatic
lobectomies, and esophagectomies. The later finding is not surprising as the volume
of these cases tend to be clustered at higher volume centers with a strong presence
of surgery fellows, which means most residents in training have a limited exposure
to these cases.
In a similar vein, the readiness of residents for surgical practice became a vital
issue as residents began to graduate wholly trained under the ACGME guidelines
that began in 2003. Napolitano et al. surveyed “young surgeons” and “older sur-
geons” about their readiness for surgical practice after graduation and found sig-
nificantly differing views [ 34 ]. The surveyed young surgeons were Fellows of the
American College of Surgeons (ACS) less than age 45, while the older surgeons
were also ACS Fellows over the age of 45. The response rate in this survey was
10% in both groups; 94% of young surgeons agreed or strongly agreed they were
ready for practice after graduation, whereas 59% of older surgeons agreed or
strongly agreed with that statement. A similar disparity was evident when asked if
they were ready for a surgery attending role. The older surgeons’ comments were
directed mainly at issues with residency training and limited work hours, while
younger surgeons’ comments were centered on unfamiliarity with the business side
of surgery.
Other literature has been published that examined the effects of duty-hour
reforms on graduating surgical resident case volumes before and after the change.
Ferguson et al. reported that at Harvard Medical School, case volume in general and
vascular surgery did not change during this period [ 35 ]. It was noted that graduating
chief residents (PGY-5) performed more cases after the duty-hour reforms went into
effect, mainly due to increased cases on their private practice general surgery ser-
vice. The case volumes of the PGY-1 through PGY-4 residents did not change dur-
ing the transition period. Other single institution reports painted a bleaker picture of
resident operative volume as a result of the duty-hour changes. In a report from
9 Resident Duty Hours in Surgical Education