Surgeons are tremendously dedicated to the delivery of optimal care. The commitment of generations of surgeons affects the care of a modern vascular surgery patient, now treated with a host of open and endovascular options. This solid work ethic, coupled with personal, professional, and organizational obligations, often leads to a routine consisting of long hours, frequent nights on call, and expectations of performing a normal day of work post-call.
Since the Institute of Medicine released the report To Err Is Human: Building a Safer Health System in 1999, greater emphasis has been placed on improving patient safety and reducing complications.1 As a result, many policies, such as those intended to prevent wrong site surgery or medication errors, have been implemented.2,3 Additionally, new resident duty-hour restrictions were introduced in 2003.4 Although the effect of duty-hour restrictions on patient safety remains unclear, the trainee’s quality of life has improved.5
In contrast, no duty-hour restrictions have been developed for attending surgeons. Consequently, many attendings work extended hours that may increase patient risk.6 A study published in the Journal of the American Medical Association in 2009 suggested a link between fatigue and surgical performance. In the study, complications for elective day surgery were found to be significantly higher (6.5 percent versus 3.4 percent) when the attending surgeon had less than six hours of sleep opportunity the night before.7
Extended hours and frequent call may also increase the risk of surgeon burnout and depression. Shanafelt and colleagues identified several independent risk factors for burnout, including the number of nights on call per week and the number of hours worked per week.8 Despite this potential increased risk to patients and risk of burnout for surgeons, alternative mechanisms of workload distribution have been only narrowly implemented. One possible explanation is the perceived cost of duty-hour restrictions. For instance, estimates indicate that if physicians were restricted to aviation industry duty-hour rules, health care costs would increase $80.4 billion annually, or $1 million per life year saved, and would require a 71 percent increase in physician workforce.9
The authors recently modified the call system within their group practice with the goal of maintaining the highest level of patient safety possible while improving the vascular surgeons’ quality of life and reducing the odds of burnout.
The Spectrum Health Medical Group is a 600-plus-member multispecialty physician group that serves a large portion of western Michigan. The vascular group consists of six board-certified vascular surgeons who share call equally. They are compensated using a work relative value unit (wRVU) model in which income is equally distributed. The group performs procedures at one hospital, covers consultations at another institution, and staffs a stand-alone vein center.
The group adheres to the philosophy of the “equivalent actor” as described by Amalberti and colleagues.10 Using this model, a team of vascular surgeons considers each member to be interchangeable in his or her ability to care for patients, which means the concept of the autonomous health care professional has largely been abandoned.10 As a result, vascular surgery patients in the hospital are treated with a team approach. Each weekday morning, the vascular surgery staff, including attendings, residents, fellows, and nurses meet to discuss each patient. If an inpatient requires intervention, the next available time and surgeon are selected. The vascular staff assumes collective responsibility for each patient.
Call schedule modifications
The call schedule was modified on July 1, 2011. Weekend call has remained the same following the call schedule modification. One member of the group takes primary call (from 7:00 am on Friday to 7:00 am on Monday), and one member is available as backup. The primary call surgeon must be available for emergency cases and will occasionally perform semi-emergent cases. The backup call surgeon must be available for emergencies, but his or her services are rarely required.
Before the new call system was implemented, each member of the group took weekday call (7:00 am Monday to 7:00 am Thursday) one day at a time, and each group member was required to work a normal day post-call. After implementation, the weekend primary call surgeon covered call Monday through Thursday from 6:00 pm to 7:00 am. (This surgeon has no clinical responsibility from 7:00 am to 6:00 pm.) During this time, the surgeon will generally perform emergent and semi-emergent cases. Additionally, this surgeon will sometimes finish outstanding elective cases begun during the day. The volume of operations performed, and therefore the number of hours worked, is primarily dictated by emergent activity and is thus highly variable. The call responsibilities rotate among the six vascular surgeons, so each surgeon is on call every sixth week.
The surgeons’ productivity was measured by determining the mean and standard deviation of the total combined wRVUs they generated for each month of the 2011 calendar year—six months before and six months following the call schedule modification. Total combined encounters for the six vascular surgeons were determined for a period of 24 months—12 months before and 12 months after the call schedule modification. Any change in patient safety was not measured directly from patient outcomes, but was indirectly inferred based upon data gathered from the vascular surgeons. Christopher M. Chambers, MD, PhD, FACS, co-author of this article, developed a Likert scale questionnaire featuring a series of questions with a rating score from one to five, where one represented “strongly disagree” and five represented “strongly agree.” The questionnaire was presented to each member of the group and responses were summarized with data presented as a mean of the six respondents. The responses to the questionnaire were obtained before the collection of the productivity data and six months following the implementation of the call schedule modification.
Although the study did not measure patient outcomes before and after the call schedule modification, the Likert scale questionnaire did attempt to determine if members of the group perceived a difference in the quality of patient care during the study period (see table, questions A–C). The individuals felt strongly that, prior to the call system changes, they had operated while sleep-deprived (Likert score 4.3) and that the new call system had improved the quality of patient care (Likert score 4.5). The perceived improved quality of care may be related to surgeons no longer performing elective day surgery following a night on call. In addition, the surgeons believe that patient care is often expedited after having a dedicated night surgeon (Likert score 4.8).
Likert Scale questionnaire results
|Letter||Question||Mean Likert score|
|A||As an attending, you have performed surgery while severely sleep-deprived.||4.3|
|B||The new call schedule has improved the quality of patient care.||4.5|
|C||Patient care is often expedited after having a dedicated night surgeon.||4.8|
|D||The new call schedule has improved your quality of life.||4.6|
|E||The new call schedule has improved the relationship with your family.||4.1|
|F||The new call schedule has improved the relationship with your vascular surgery partners.||4.0|
|G||The biggest advantage of the new call system is that it allows you to spend more time with family and have personal scheduled time off during the week.||4.7|
|H||The group should continue this call system.||4.8|
Questions related to patient care=A–C. Questions related to surgeon quality of life=D–G. Question related to group satisfaction with new call system=H.
The number of nights on call per week and the number of hours worked per week are both independent risk factors for surgeon burnout. Following the implementation of the new call schedule, the surgeons strongly agreed that their quality of life improved (Likert score 4.6). Relationships with their families (Likert score 4.1) and with their vascular surgery partners (Likert score 4.0) were both felt to have improved (see table, Questions D–G). Those surveyed strongly agreed that the new call system allowed more time with family and personal scheduled time off during the week (Likert score 4.7).
One barrier to call system modification was the potential loss of revenue. Productivity was measured by total wRVUs generated by the six surgeons for a 12-month period, six months before and six months after the call system change. Data are shown in Figure 1 The difference between the two six-month periods was minor. Mean total practice wRVUs per month was 4,852 + 564 before and 4,772 + 362 (p=0.41) after the call schedule change.
The group’s productivity was also assessed by determining total patient encounters each month for a period of 12 months before and 12 months following the call schedule change (Figure 2). No significant difference was noted following the call schedule change. The total number of patient consults and operations by the group in the 12 months before the call system change was 20,945 and 20,910 for the 12-month period after the call system change.
The final question of the Likert scale questionnaire relates to the individual’s satisfaction with the new call schedule after the initial six-month period. There was strong agreement that the new call system should be continued (see table, question H, Likert score 4.8).
Efforts to reshape health care systems to resemble ultra-safe industries are under way. Adoption of system processes such as the operative “time out” have been shown to improve safety and decrease perioperative complications.11,12 Nonetheless, preventable errors still occur with distressing frequency.13 For example, The Joint Commission reports approximately 40 wrong site surgeries per month in the U.S.14
Both staff surgeons and trainees have traditionally worked extensive hours. Prolonged wakefulness produces fatigue, which is believed to negatively affect performance. As a result, high-risk industries such as aviation have limited duty hours.9 A major change among medical care professionals was the establishment of duty-hour restrictions for physicians in training. An unintended consequence of the resident work-hour restrictions, however, is that staff surgeons may work longer hours and frequently perform elective surgery following a night on call, sometimes without sleep opportunity. The outcomes of daytime operations performed by surgeons with less than and greater than six hours of sleep opportunity were examined, and the number of complications was significantly higher in daytime surgeries performed by surgeons with less than six hours sleep opportunity (6.5 versus 3.4 percent, odds ratios, 1.47; 95 percent confidence intervals, 0.96–2.27).7
Health insurers are increasingly likely to deny reimbursement for complications arising from surgical errors. The Centers for Medicare & Medicaid Services (CMS) has had payment programs in place for many years to reimburse for a standard of care through diagnosis-related group payments that do not necessarily include payment for ancillary co-morbidities. Additionally, payment is denied for many hospital-acquired infections.3
In 2011, CMS published the final rules for the Value-Based Purchasing Program in the Federal Register. This program combines some measures from the existing Hospital Inpatient Quality Reporting Program to provide incentive payments based on quality measures.15 Commercial health insurance plans often adopt Medicare payment policies, further increasing the financial impact on quality-related errors in the future. The potential for decreased reimbursement resulting from surgical errors increases the benefit of a reduction in continuous work hours.
Due to occupational stresses, professional burnout is a real concern for surgeons—a comprehensive national survey documented a 40 percent burnout rate.8 Several factors were independently associated with burnout, including the subspecialty choice of vascular surgery. Additional factors associated with burnout include the number of hours worked per week and the number of nights on call per week.
The revised night float call system implemented in the authors’ practice—in which one surgeon on the team doesn’t perform surgery during the day one out of every six weeks—has significantly improved the quality of life for the surgeons and established a predictable call schedule. Limiting the on-call surgeon to nights had two positive effects for the surgeon’s quality of life. First, the on-call surgeon believed he was not overworked or stressed, having the day to rest. Second, the on-call surgeons found that they were able to get home in the early evening more frequently and spend more time with their families.
In an era of decreasing reimbursement and increasing expectation of productivity, changing to a night float call system may seem impractical. However, the development of this call system, and its subsequent improvement in surgeon quality of life, has been realized without a loss in productivity. The system was created without the predicted need of adding surgeons to the practice in part because of movement toward the equivalent actor model. This model of care has allowed significant improvements in the efficiency of delivering care to both elective and emergent vascular surgery patients, and when coupled with a compensation model of equal revenue sharing, professional teamwork has developed and grown among the surgeons. These results have led to expedited care of patients in need of surgical procedures. A call schedule change to create a night float system improved the surgeons’ quality of life without decreasing productivity. Additionally, the new call schedule eliminated the need to perform elective procedures post-call, potentially improving patient safety and quality of care.
- Kohn LT, Corrigan JM, Donaldson MS (eds). To Err Is Human: Building A Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press, 2000.
- The Joint Commission. 2012 National Patient Safety Goals. Available at: http://www.jointcommission.org/mobile/standards_information/national_patient_safety_goals.aspx. Accessed March 10, 2014.
- Medicare Program. Changes to the Hospital Inpatient Prospective Payment Systems and fiscal year 2009 rates. Federal Register. 2008;73(161):48434-49083.
- Accreditation Council for Graduate Medical Education. ACGME role and taskforce. Available at: http://www.acgme.org/acgmeweb/tabid/286/GraduateMedicalEducation/DutyHours/Archive/ACGMERoleandTaskForce.aspx. Accessed March 10, 2014.
- Pape HC, Pfeifer R. Restricted duty hours for surgeons and impact on residents’ quality of life, education, and patient care: A literature review. Patient Saf Surg. 2009;3(1):3.
- MacDonald NE, Hebert PC, Flegel K, Stanbrook MB. Working while sleep-deprived: Not just a problem for residents. CMAJ. 2011;183(15):1689.
- Rothschild JM, Keohane CA, Rogers S, Gardner R, Lipsitz SR, Salzberg CA, Yu T, Yoon CS, Williams DH, Wien MF, Czeisler CA, Bates DW, Landrigan CP. Risks of complications by attending physicians after performing nighttime procedures. JAMA. 2009;302(14):1565-1572.
- Shanafelt TD, Balch CM, Bechamps GJ, Russell T, Dyrbye L, Satele D, Collicott P, Novotny PJ, Sloan J, Freischlag JA. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463-471.
- Payette M, Chatterjee A, Weeks WB. Cost and workforce implications of subjecting all physicians to aviation industry work-hour restrictions. Am J Surg. 2009;197(6):820-825.
- Amalberti R, Auroy Y, Berwick D, Barach P. Five system barriers to achieving ultrasafe health care. Ann Intern Med. 2005;142(9):756-764.
- Makary MA, Holzmueller CG, Thompson D, Rowen L, Heitmiller ES, Maley WR, Black JH, Stegner K, Freischlag JA, Ulatowski JA, Pronovost PJ. Operating room briefings: Working on the same page. Jt Comm J Qual Patient Saf. 2006;32(6):351-355.
- Altpeter T, Luckhardt K, Lewis JN, Harken AH, Polk HC Jr. Expanded surgical time out: A key to real-time data collection and quality improvement. J Am Coll Surg. 2007;204(4):527–532.
- Agency for Healthcare Research and Quality. 2011 National Healthcare Quality Report. Available at: http://www.ahrq.gov/research/findings/nhqrdr/nhqr11/index.html. Accessed March 20, 2014.
- Boodman SG. The pain of wrong site surgery. The Washington Post. Available at: http://www.washingtonpost.com/national/the-pain-of-wrong-site-surgery/2011/06/07/AGK3uLdH_story.html. Accessed November 13, 2012.
- Medicare Program. Hospital inpatient value-based purchasing program. Federal Register. 2011;76(88):26498, 26544.