Charles M. Ferguson

The Impact of the 80-Hour Resident Workweek on Surgical Residents and Attending Surgeons

Objective:To assess the impact of the 80-hour resident workweek restrictions on surgical residents and attending surgeons. Summary Background Data:The ACGME mandated resident duty hour restrictions have required a major workforce restructuring. The impact of these changes needs to be critically evaluated for both the resident and attending surgeons, specifically with regards to the impact on motivation, job satisfaction, the quality of surgeon training, the quality of the surgeons life, and the quality of patient care. Methods:Four prospective studies were performed at a single academic surgical program with data collected both before the necessary workforce restructuring and 1 year after, including: 1) time cards to assess changes in components of daily activity; 2) Web-based surveys using validated instruments to assess burnout and motivation to work; 3) structured, taped, one-on-one interviews with an external PhD investigator; and 4) statistical analyses of objective, quantitative data. Results:After the work-hour changes, surgical residents have decreased “burnout” scores, with significantly less “emotional exhaustion” (Maslach Burnout Inventory: 29.1 “high” vs. 23.1 “medium,” P = 0.02). Residents have better quality of life both in and out of the hospital. They felt they got more sleep, have a lighter workload, and have increased motivation to work (Herzberg Motivation Dimensions). We found no measurable, statistically significant difference in the quality of patient care (NSQIP data). Resident training and education objectively were not statistically diminished (ACGME case logs, ABSITE scores). Attending surgeons perceived that their quality of their life inside and outside of the hospital was “somewhat worse” because of the work-hour changes, as they had anticipated. Many concerns were identified with regards to the professional development of future surgeons, including a change toward a shift-worker mentality that is not patient-focused, less continuity of care with a loss of critical information with each handoff, and a decrease in the patient/doctor relationship. Conclusion:Although the mandated restriction of resident duty hours has had no measurable impact on the quality of patient care and has led to improvements for the current quality of life of residents, there are many concerns with regards to the training of professional, responsible surgeons for the future.

Factors associated with successful laparoscopic cholecystectomy for acute cholecystitis.

OBJECTIVE This article determined which preoperative data correlated with successful completion of a laparoscopic cholecystectomy in patients with acute cholecystitis. SUMMARY BACKGROUND DATA Although laparoscopic cholecystectomy is the procedure of choice in chronic cholecystitis, its use in acute cholecystitis may be associated with higher costs and complication rates. It is not known which patients with acute cholecystitis are likely to require conversion to open cholecystectomy based on preoperative data or if a cooling-off period with medical therapy can diminish inflammation and increase the chance of successful laparoscopic cholecystectomy. METHODS All laparoscopic cholecystectomies done by the authors between 10/90 and 2/92 were reviewed. Data on cases of acute cholecystitis were prospectively collected on standardized data forms. RESULTS Twenty of 281 laparoscopic cholecystectomies were done for acute cholecystitis; 7/20 patients with acute cholecystitis required conversion to open cholecystectomy compared with 6/281 patients undergoing elective operation for chronic cholecystitis. In patients with acute cholecystitis the interval from admission to cholecystectomy in the successful cases was 0.6 days vs. 5 days in the cases requiring conversion to open cholecystectomy (p = .01). Cases requiring conversion to open cholecystectomy also had higher WBC (14.0 vs. 9.0, p < .05), alkaline phosphatase (206 vs. 81, p < .02, and APACHE II scores (10.6 vs. 5.1, p < .05). Ultrasonographic findings such as gallbladder distention, wall thickness, and pericholecystic fluid did not correlate with the success of laparoscopic cholecystectomy. Patients converted from laparoscopic to open cholecystectomy required more operating room time (120 min vs. 87 min, p < .01) and more postop hospital days (6 vs. 2, p < .001). CONCLUSIONS Laparoscopic cholecystectomy for acute cholecystitis should be done immediately after the diagnosis is established because delaying surgery allows inflammation to become more intense, thus increasing the technical difficulty of laparoscopic cholecystectomy.

Recurrent gallstone ileus: third time is the charm.

We report herein the case of a 57-year-old man who presented after the third occurrence of gallstone ileus. The patient underwent successful enterolithotomy, partial cholecystectomy, and repair of choledochoduodenal fistula. Although recurrent gallstone ileus is relatively rare, its occurrence is an indication for definitive management of the biliary-enteric fistula.

Effects of a Surgical Skills Boot Camp

irect injury to the blood vessel and bile duct. In severe acute r chronic cholecystitis, the true value of CVS might be injury inimization rather than protection, by lowering the threshld for conversion to the open procedure or performing a outine intraoperative cholangiography. When more adverse onditions in Calot triangle are encountered, such as in Miizzi syndrome, any effort to attain the CVS should be avoided ecause of increased frequency of coexistent anomalous right epatic duct and inescapable risk of bile duct injury. To clarify the protective effect of CVS on bile duct injury uring laparoscopic cholecystectomy in the population-based tudy, registration and appraisement of the CVS is necessary. he authors suggest video images are superior to photo prints or documentation of CVS, consistent with a recent report rom The Netherlands in which the CVS is regarded as an ssential component of best practice for laparoscopic cholecysectomy and the recorded CVS is judged whether the right echnique was used in the case of a lawsuit. Given the low rate f bile duct injury in laparoscopic cholecystectomy, the costffectiveness of the CVS policy should be considered. Impleenting a rigorous system in which a short video is incorpoated into an electronic chart is probably costly. What is onsidered best practice is not always the same as what is onsidered standard of care, as seen in the performance of outine intraoperative cholangiography during laparoscopic holecystectomy in the United States.

Benign duodenocolic fistula

Three cases of benign duodenocolic fistula are presented, and the diagnosis and treatment reviewed. Patients with benign duodenocolic fistulas usually complain of diarrhea, and occasionally nausea and feculent vomiting. Physical examinations are nonspecific, revealing wasting from the chronic diarrhea. Barium enemas are usually diagnostic. Therapy consists of excision of the fistula and repair of the duodenal and colonic defects.

Trends in Attrition Rates for Surgical Faculty

I write to congratulate the authors of “A review of trends in attrition rates for surgical faculty: a case for a sustainable retention strategy to cope with demographic and economic realities,” which appeared in the May issue, and to emphasize the role of burnout in attrition and to make the authors and others aware of methods of dealing with burnout. Satiani and colleagues rightly point out that 40% of surgeons experience symptoms of burnout and 25% consider leaving their current practice within 2 years for reasons other than retirement. Unfortunately, most studies of physician burnout recommend preventative and treatment strategies aimed at the burned out individual, such as taking a vacation, exercise, regaining passion for medicine, and exercise, none of which addresses the causes of burnout so carefully elucidated by Maslach in her 1997 book, The Truth About BurnoutdHow Organizations Cause Personal Stress and What to Do About It. Although Satiani and colleagues and the accompanying excellent Invited Commentary by Freischlag allude to methods to prevent and treat burnout, I believe it is worth reviewing the principles set forth in Maslach’s book: