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Letters to the Editor to:

Topics in Training:
Michael A. Baskies, David E. Ruchelsman, Craig M. Capeci, Joseph D. Zuckerman, and Kenneth A. Egol
Operative Experience in an Orthopaedic Surgery Residency Program: The Effect of Work-Hour Restrictions
J Bone Joint Surg Am 2008; 90: 924-927 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read Letter to the Editor] Dr. Egol et al. respond to Drs. Melton and Goodwin
Kenneth A, Egol, Michael A. Baskies, MD, David E. Ruchelsman, MD, Craig M. Capeci, MD, Joseph D. Zuckerman, MD, Kenneth A. Egol, MD   (21 July 2008)
[Read Letter to the Editor] Orthopaedic training exposure can be maintained despite falling hours.
Joel TK Melton, Mark I. Goodwin, Director, Wessex Orthopaedic Training Program.   (11 July 2008)

Dr. Egol et al. respond to Drs. Melton and Goodwin 21 July 2008
Previous Letter to the Editor Top
Kenneth A, Egol,
Associate Professor & Vice Chairman
NYU Hospital for Joint Diseases,
Michael A. Baskies, MD, David E. Ruchelsman, MD, Craig M. Capeci, MD, Joseph D. Zuckerman, MD, Kenneth A. Egol, MD

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Re: Dr. Egol et al. respond to Drs. Melton and Goodwin

ljegol{at}att.net Kenneth A, Egol, et al.

We would like to thank Drs. Melton and Goodwin for their letter in response to our recent article and for the interesting data they provided from the UK system. We can appreciate their concern about the ramifications that the work-hour restrictions mandated by the European Working Time Directive have had, and will continue to have on the training of UK orthopaedic surgical trainees.

We agree that both in the American and English systems, the rigid regulation of trainees work-hours has been a major impetus for residency program directors to identify novel ways to maximize the efficiency and effectiveness of resident training in the office and in the operating theater during the allowable work-hours. We applaud the authors for having been able to maintain operative case loads for their trainees through modifications in their training system despite the enforced 56-hour work limit.

The American and English systems remain distinct with regard to overall duration and work-hour restrictions. Under the current ACGME work- hour guidelines (i.e., restriction of the hours worked by residents to eighty hours per week with a maximum of twenty-four hours in one shift; all work shifts require a separation of at least ten hours; and, each resident is required to have at least one twenty-four-hour period of "non- working" time per week), our trainees complete a five-year clinical orthopaedic training program, and most graduates from our program pursue an additional fellowship year of subspecialty clinical training. Additionally, unsupervised operating lists are not part of our training system.

It is difficult to estimate the impact that further reductions in allowable work-hours will have on American trainees. For example, within a 56-hour work limit system, an additional 24 hours of training time would be sacrificed each week on average during each year of residency training. Should additional legislation be adopted that reduces further allowable work-hours, American programs may be forced to face the same question UK programs are currently facing concerning extending the length of training.

Michael A. Baskies, MD David E. Ruchelsman, MD Craig M. Capeci, MD Joseph D. Zuckerman, MD Kenneth A. Egol, MD
Orthopaedic training exposure can be maintained despite falling hours. 11 July 2008
Next Letter to the Editor Top
Joel TK Melton,
Specialist Registrar in Trauma & Orthopaedics
Royal Bournemouth Hospital, UK,
Mark I. Goodwin, Director, Wessex Orthopaedic Training Program.

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Re: Orthopaedic training exposure can be maintained despite falling hours.

joel.melton{at}virgin.net Joel TK Melton, et al.

To The Editor:

We enjoyed reading the recently published article regarding operative experience and working time restrictions in an orthopaedic surgery residency program(1). Many of the issues discussed have been a topic of great debate in Europe for some years. Training in the United Kingdom has been affected by the phased introduction of the European Working Time Directive (2). Training hours have been required to come down from over 100 hours per week and currently set a 56 hour maximum. In August 2009, the limit will come down to 48 hours. These changes have been strongly resisted by orthopaedic surgeons and trainees. We are, however, confined to working within European law, enforced by the Department of Health of UK government.

These changes have affected training but by changing working practices and maximising training opportunities, high quality training and adequate operative case numbers can be achieved. Unsupervised operating lists have been reduced in number increasing the proportion of training lists where a trainee is directly supervised by his or her trainer. Work rotas have been designed to reduce the number of trainees required to work in evening and night time hours enabling a greater percentage of work hours to fall in the day-time where senior surgeons and training are more likely to be available. Allied health care professionals have been trained and appointed to take on some of the non-essential workload traditionally performed by the orthopaedic registrars allowing the trainee to spend more time in the clinic or in the operating theatre. The length of training programs is currently under review but at present most registrars will have spent one year as a postgraduate house officer, between two and four years as a senior house officer in surgical specialties including orthopaedics, many will have spent an additional year as a junior registrar before appointment to a six year orthopaedic registrar training program. It may be that further reductions in working hours lead to additional years of training as implicated by an 8 year specialty specific training for orthopaedics which is the current plan for trainees starting their training program.

A recent analysis of UK wide training has shown an average of 312 operative cases per year(3). This represents almost 1900 cases in training. There is some inter-program difference in operative experience and in the Wessex region a trainee sample showed that they performed on average 401 cases per year before the reduction of hours and 332 cases in 12 months after the 56 hour limit was imposed.

Decreased working hours seem to be inevitable for trainee surgeons in all specialties but with careful workforce planning, working pattern changes and maximising training opportunities, it does seem possible to maintain adequate training exposure and operative numbers.

The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

References:

1. Baskies MA, Ruchelsman DE, Capeci CM, Zuckerman JD, Egol KA. Operative experience in an orthopaedic surgery residency program: the effect of work-hour restrictions. J Bone Joint Surg Am. 2008;90:924-927.

2. The Working Time Regulations 1998, ISBN 0 11 079410 9.

3. Insights into trauma and orthopaedic training from the ‘elogbook’. Syed TA, Lamb A, Reed M, Sher S, Freudman M, Marx C, Wallace A. Education section of British Orthopaedic Association Website.