Five Uneasy Peaces: Perfect Storm Meets Professional Autonomy in Surgical Education

Journal of the American College of Surgeons

Volumn 202, Issue 6, 2006, Pages 953-966

  Nauta, Russell J ^a  

^a HARVARD MEDICAL SCHOOL   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

AMBIVALENCE; AUTOREGULATION; COMPUTER SIMULATION; CONTINUING EDUCATION; EVIDENCE BASED MEDICINE; FATIGUE; HUMAN; IDENTITY; LEARNING; LOGGING; MATHEMATICAL ANALYSIS; MEDICAL EDUCATION; MEDICAL LITERATURE; MEDICAL PROFESSION; MEDICAL STUDENT; POSTGRADUATE EDUCATION; PRIORITY JOURNAL; PROFESSIONALISM; PUBLICATION; RESIDENCY EDUCATION; REVIEW; SURGICAL TRAINING;

EDUCATION, MEDICAL, GRADUATE; GUIDELINES; HUMANS; SURGERY; UNITED STATES;

EID: 33646825525     PISSN: 10727515     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.jamcollsurg.2006.02.029     Document Type: Review

References (188)

1. Wylie C.D. Sleep, science, and policy change. N Engl J Med 352 (2005) 196-197
2. Prinz R. Education, economics, and excellence. Arch Surg 139 (2004) 469-475
3. Fischer J. Continuity of care. a casualty of the 80-hour work week. Acad Med 79 (2004) 381-383
4. Brennan M., and Debas H. Surgical education in the United States. portents for change. Ann Surg 240 (2004) 565-572
5. Accreditation Council for Graduate Medical Education. Chicago [c2000-2005]. Mission statement. Available at: http://www.acgme.org.acwebsite/about/ab_mission.asp. Accessed September 13, 2005.
6. Russell T. The college viewpoint. Arch Surg 136 (2001) 151-153
7. Russell T. From my perspective. Bull Am Coll Surg 91 (2006) 4-5
8. Blumenthal D. New steam from an old cauldron-the physician-supply debate. N Engl J Med 350 (2004) 1780-1787
9. Joyner B. An historical review of graduate medical education and a protocol of accreditation council for graduate medical education compliance. J Urol 172 (2004) 34-39
10. Bonjer H., and Bruining H. Surgery in the Netherlands. Arch Surg 134 (1999) 92-98
11. Wallack M., and Chao L. Resident work hours. the evolution of a revolution. Arch Surg 136 (2001) 1426-1432
12. Rutkow I. Surgery-an illustrated history (1993), Mosby, St Louis, MO
13. Van Eaton E., Horvath K., and Pellegrini C. Professionalism and the shift mentality. how to reconcile patient ownership with limited work hours. Arch Surg 140 (2005) 230-235
14. Robins N. The girl who died twice: every patient's nightmare: the Libby Zion case and the hidden hazards of hospitals (1999), Delacorte Press, New York
15. Asch D., and Parker R. The Libby Zion case-one step forward or two steps backward?. N Engl J Med 318 (1988) 771-775
16. Kohn L., Corrigan J., and Donaldson M. To err is human. building a safer health system (2000), National Academies Press, Washington, DC
17. Berwick D. A primer on leading the improvement of systems. Br Med J 312 (1996) 619-622
18. Aufses A.H. Residency training programs then and now. surgery. Mt Sinai J Med 56 (1989) 367-369
19. Greater New York Hospital Association. Recommendations of New York State Department of Health's Ad Hoc Advisory Committee on Emergency Services, New York (1987) August
20. New York State Department of Health. Medical Staff in New York Codes, Rules and Regulations (1998) 10.§405.4
21. Dine D.D. New York limits interns' hours. Mod Healthc 88 (1988) 4
22. Bell B.M. Surgeons and the fate of graduate medical education [letter]. Acad Med 67 (1992) 251
23. Petersdorf R.G., and Bentley J. Residents' hours and supervision. Acad Med 64 (1989) 175-181
24. Thorpe K.E. House staff supervision and work hours. implications of regulatory change in New York state. JAMA 263 (1990) 3177-3181
25. Dine D.D. New York adjusts to restricted resident hours. Mod Healthc 19 (1989) 36-37
26. Pallarito K. Experts still deliberating effectiveness on N.Y. rules limiting residents' hours. Mod Healthc 20 (1990) 41
27. Accreditation Council for Graduate Medical Education. Chicago. ACGME highlights its standards on residents duty hours (2001). http://www.acgme.org. May. Available at: http://www.acgme.org. Accessed June 18, 2001
28. Reiner S.C. The impact of the new code regulations on postgraduate medical education in New York state. NY State J Med 89 (1989) 457-461
29. American College of Surgeons. Fundamental characteristics of surgical residency programs. Am Coll Surg Bull 73:22-23.
30. Bell B. Supervision, not regulation of hours, is the key to improving the quality of patient care. JAMA 269 (1993) 403-404
31. Adams D. OSHA says "no" to 80-hour workweek for residents. Am Med Assoc AMNews (2002)
32. Patient and Physician Safety and Protection Act of 2002, S. 2614,107th Cong. 2nd Sess. (2002).
33. Evans L. Regulatory and legislative attempts at limiting medical resident work hours. J Leg Med 23 (2002) 251-267
34. Ponsky J. Addressing the "general competencies". what is this all about?. Surgery 135 (2004) 1-3
35. Dunnington G., and Williams R. Addressing the new competencies for residents' surgical training. Acad Med 78 (2003) 14-21
36. Trunkey D., Russell T., and Dunnington G. Competencies. Arch Surg 138 (2003) 672-680
37. Van Eaton E., Horvath K., Lober W., et al. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg 200 (2005) 538-545
38. Junger S. The perfect storm (1998), HarperCollins, New York
39. Leach D. Residents' work hours. the achilles heel of the profession?. Acad Med 75 (2000) 1156-1157
40. Pellegrini C. Invited commentary. the ACGME "outcomes project.". Surg 131 (2002) 214-215
41. DaRosa D., Bell Jr. R., and Dunnington G. Residency program models, implications, and evaluation. results of a think tank consortium on resident work hours. Surg 133 (2003) 13-23
42. Ritchie W. Basic certification in surgery by the American Board of Surgery (ABS). what does it mean? Does it have value? Is it relevant? A personal opinion. Ann Surg 239 (2004) 133-139
43. Debas H., Bass B., Brennan M., et al. American Surgical Association blue ribbon committee report on surgical education. 2004. Ann Surg 241 (2005) 1-8
44. NRMP data (1998), National Resident Match Program, Washington, DC April
45. NRMP data (2005), National Resident Match Program, Washington, DC April
46. Fischer J. Surgeons. employees or professionals?. Am J Surg 190 (2005) 1-3
47. Friedmann P. House staff work hours, supervision, and quality of care. JAMA 269 (1993) 2987-2988
48. Leapfroggroup.com. The Leapfrog Group for patient safety rewarding higher standards (2005). http://www.leapfroggroup.org. Available at: http://www.leapfroggroup.org. Accessed December 17
49. McClellan RN, ed. Selected readings in general surgery. Dallas: Lippincott Williams & Wilkins Co.
50. American College of Surgeons. Surgical education and self-assessment program [syllabus]. Chicago: American College of Surgeons.
51. Wade T., and Kaminski D. Comparative evaluation of educational methods in surgical resident education. Arch Surg 130 (1995) 83-87
52. Gold J., Begg W.B., Fullerton D., et al. Successful implementation of a novel internet hybrid surgery curriculum. the early phase outcome of thoracic surgery prerequisite curriculum e-learning project. Ann Surg 240 (2004) 499-509
53. th Annual NESS Meeting. Massachusetts General Hospital. Boston, MA.
54. Lewis F. The American Board of Surgery. Bull Am Coll Surg 90 (2005) 34-38
55. Pellegrini C., Warshaw A., and Debas H. Residency training in surgery in the 21st century. a new paradigm. Surgery 136 (2004) 953-965
56. Peracchia A. Surgical education in the third millennium. Ann Surg 234 (2001) 709-712
57. Clavien P., Nahrwold D., Soper N., et al. Physician competency? Teaching old dogs new tricks. J Gastrointestinal Surg 9 (2005) 625-632
58. Korndorffer J.R., Stefanidis D., and Scott D.J. Laparoscopic skills laboratories. current assessment and a call for resident training standards. Am J Surg 191 (2006) 17-22
59. McGreevy J. The aviation paradigm and surgical education. J Am Coll Surg 201 (2005) 110-117
60. Ericsson K.A., Krampe R.T., and Tesch-Romer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev 100 (1993) 363-406
61. Ericsson K.A. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 79 (2004) S70-S81
62. Gallagher A., Ritter E., Champion H., et al. Virtual reality simulation for the operating room. proficiency-based training as a paradigm shift in surgical skills training. Ann Surg 241 (2005) 364-372
63. Stefanidis D., Sierra R., Korndorffer J.R., et al. Intensive continuing medical education course training on simulators results in proficiency for laparoscopic suturing. Am J Surg 191 (2006) 23-27
64. Paisley A., Baldwin P., and Paterson-Brown S. Validity of surgical simulation for the assessment of operative skill. Br J Surg 88 (2001) 1525-1532
65. Lave J., and Wenger E. Stipulated learning. Legitimate peripheral participation (1991), Cambridge University Press, Cambridge, UK
66. Bann S., Davis I., Moorthy K., et al. The reliability of multiple objective measures of surgery and the role of human performance. Am J Surg 189 (2005) 747-752
67. Sutton C., McCloy R., Middlebrook A., et al. MIST VR. A laparoscopic surgery procedures trainer and evaluator. Stud Health Technol Inform 39 (1997) 598-607
68. Aggarwal R., Grantcharov T., Moorthy K., et al. A competency-based reality training curriculum for the acquisition of laparoscopic psychomotor skill. Am J Surg 191 (2006) 128-133
69. Vygotsky L.S. Thought and language (1962), MIT Press, Cambridge, MA
70. Kneebone R. Evaluating clinical simulations for learning procedural skills. a theory-based approach. Acad Med 80 (2005) 549-553
71. Wertsch J.V. Vygotsky and the social formation of mind (1985), Harvard University Press, Cambridge, MA
72. Martin J., Regehr G., Reznick R., et al. Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg 84 (1997) 273-278
73. Faulkner H., Regehr G., Martin J., et al. Validation of an objective structured assessment of technical skill for surgical residents. Acad Med 71 (1996) 1363-1365
74. Reznick R., Regehr G., MacRae H., et al. Testing technical skill via an innovative "bench station" examination. Am J Surg 173 (1997) 220-230
75. Vassiliou M., Feldman L., Andrew C., et al. A global assessment tool for evaluation of intraoperative laparoscopic skills. Am J Surg 190 (2005) 107-113
76. Seymour N., Gallagher A., Sanziana R., et al. Virtual reality training improves operating room performance. Ann Surg 236 (2002) 458-464
77. Macmillan A., and Cuschieri A. Assessment of innate ability and skills for endoscopic manipulations by the Advanced Dundee Endoscopic Psychomotor Tester. predictive and concurrent validity. Am J Surg 177 (1999) 274-277
78. Ritchie Jr. W., Rhodes R., and Biester T. Work loads and practice patterns of general surgeons in the United States, 1995-1997. a report from the American Board of Surgery. Ann Surg 230 (1999) 533-552
79. Parsa C., Organ C., and Barkan H. Changing patterns of resident operative experience from 1990 to 1997. Arch Surg 135 (2000) 570-575
80. Gandhi T. Fumbled handoffs. one dropped ball after another. Ann Intern Med 142 (2005) 352-357
81. The trouble with shortening residency hours. Yale Journal of Public Health [online] (2005). http://www.yaleph.com/archive/vol1no2/story5.html. Available at: http://www.yaleph.com/archive/vol1no2/story5.html. Accessed March 28, 2005
82. Recreating the residency. Yale Medicine Fall/Winter 2004 [online] (2005). http://www.med.yale.edu/external/pubs/ym_fw04/residency.html. Available at: http://www.med.yale.edu/external/pubs/ym_fw04/residency.html. Accessed March 28, 2005.
83. Healy G.B., Barker J., and Madonna G. Error reduction through team leadership. applying aviation's CRM model in the OR. Bull Am Coll Surg 91 (2006) 10-13
84. Richardson J. Workforce and lifestyle issues in general surgery training and practice. Arch Surg 137 (2002) 515-520
85. Shivley E., and Shivley S. Threats to rural surgery. Am J Surg 190 (2005) 200-205
86. Joyner B., Siedel K., Stoll D., et al. Report of the National Survey of Urology Program Directors. attitudes and actions regarding the Accreditation Council for Graduate Medical Education Regulations. J Urol 175 (2005) 1961-1968
87. Rotondo M.F., Esposito T.J., Reilly P.M., et al. The position of the eastern association for the surgery of trauma on the future of trauma surgery. J Trauma 59 (2005) 77-79
88. Kaplan L.J., Frankel H.L., Hojman H., et al. What price for general surgery?. J Trauma 59 (2005) 390-394
89. Karnell L. Residency manpower trends. Am Coll Surg Bull 76 (1991) 26-27
90. Bland K. The impact of surgical fellowships on choice of an academic career. Bull Am Coll Surg 85 (2000) 17-23
91. Ferguson C. The arguments against fellowship training and early specialization in general surgery. Arch Surg 138 (2003) 915-916
92. Fernandez-Cruz L. General surgery as education, not specialization. Ann Surg 240 (2004) 932-938
93. Zinner M.J. Surgical residencies. are we still attracting the best and the brightest?. Bull Am Coll Surg 87 (2002) 20-25
94. O'Herrin J., Lewis B., Rikkers L., et al. Why do students choose careers in surgery?. J Surg Res 119 (2004) 124-129
95. Ko C., Whang E., Karamanoukian R., et al. What is the best method of surgical training?A report of America's leading senior surgeons. Arch Surg 133 (1998) 900-905
96. Kozar R., Anderson K., Escobar-Chaves S., et al. Preclinical students. who are surgeons?. J Surg Res 119 (2004) 113-116
97. Bland K., and Isaacs G. Contemporary trends in student selection of medical specialties. the potential impact on general surgery. Arch Surg 137 (2002) 259-267
98. Britt L. "Halstedian 2" residency training. Arch Surg 137 (2002) 271-273
99. Polk H. The declining interest in surgical careers, the primary care mirage, and concerns about contemporary undergraduate surgical education. Am J Surg 178 (1999) 177-178
100. Krizek T. Ethics and philosophy lecture. surgery . . . is it an impairing profession?. J Am Coll Surg 194 (2002) 352-366
101. National Center for Education Statistics. Digest of education statistics (2003). http://www.nces.ed.gov. Available at: http://www.nces.ed.gov. Accessed August 23, 2005.
102. Levinson W., Kaufman K., Clark B., et al. Mentors and role models for women in academic medicine. West J Med 154 (1991) 423-426
103. Kram K. Mentoring at work. developmental relationships in organizational life (1985), Scott Foresman, Glenview IL
104. Singletary S.E. Mentoring surgeons for the 21st century. Ann Surg Oncol 12 (2005) 848-860
105. Cochran A., Paukert J., Scales E., et al. How medical students define surgical mentors. Am J Surg 187 (2004) 698-701
106. Cochran A., Melby S., and Neumayer L. An internet-based survey of factors influencing medical student selection of a general surgery career. Am J Surg 189 (2005) 742-746
107. Gabram S., Allen L., and Deckers P. Surgical residents in the 1990s. issues and concerns for men and women. Arch Surg 130 (1995) 24-28
108. Arnold M., Patterson A., and Tang L. Has implementation of the 80-hour work week made a career in surgery more appealing to medical students?. Am J Surg 189 (2005) 129-133
109. Gabram S., Hoenig J., Schroeder J., et al. What are the primary concerns of recently graduated surgeons and how do they differ from those of the residency training years?. Arch Surg 136 (2001) 1109-1114
110. van Dis J. STUDENTJAMA. Residency training and pregnancy. JAMA 291 (2004) 636-638
111. Saalwachter A., Freischlag J., Sawyer R., et al. The training needs and priorities of male and female surgeons and their trainees. J Am Coll Surg 201 (2005) 199-204
112. Yedidia M.J., and Bickel J. Why aren't there more women leaders in academic medicine? The views of clinical department chairs. Acad Med 76 (2001) 453-465
113. Ragins B.R., and Cotton J.L. Mentor functions and outcomes. a comparison of men and women in formal and informal mentoring relationships. J Appl Psychol 84 (1999) 529-550
114. Hurley A.E., and Fagenson-Eland E.A. Challenges in cross-gender mentoring relationships. psychological intimacy, myths, rumours, innuendoes and sexual harassment. Leadersh Organ Dev J 17 (1996) 42-49
115. Schroen A., Brownstein M., and Sheldon G. Women in academic general surgery. Acad Med 79 (2004) 310-318
116. Frank E., Brogan D., and Schiffman M. Prevalence and correlates of harassment among US women physicians. Arch Int Med 158 (1998) 352-358
117. Lillemoe K.D., Ahrendt G.M., Yeo C.G., et al. Surgery. still an "old boys" club?. Surgery 116 (1994) 255-261
118. Minter R., Gruppen L., Napolitano K., et al. Gender differences in the self-assessment of surgical residents. Am J Surg 189 (2005) 647-650
119. Alexander D., and Bushell I. Coping with night call: part I: understanding the benefits and challenges of traditional call. Hosp Physician (1999) 53-69
120. Fischer J. Abandonment. J Gastrointestinal Surg 7 (2003) 827-830
121. Lewis F. Should we limit resident work hours?. Ann Surg 237 (2003) 458-459
122. Henningsen J. Why the numbers are dropping in general surgery. Arch Surg 137 (2002) 255-256
123. Fischer J. We hold these truths.... Arch Surg 130 (1995) 1156-1158
124. Friedman R., Bigger J., and Kornfeld D. The intern and sleep loss. N Engl J Med 285 (1971) 201-203
125. Hawkins M., Vichick D., Silsby H., et al. Sleep and nutritional deprivation and performance of house offices. J Med Educ 60 (1985) 530-535
126. Asken M., and Raham D. Resident performance and sleep deprivation. a review. J Med Educ 58 (1983) 382-388
127. Dawson D., and Reid K. Fatigue, alcohol and performance impairment. Nature 388 (1997) 235
128. Weinger M., and Ancoli-Israel S. Sleep deprivation and clinical performance. JAMA 287 (2002) 955-957
129. Samkoff J., and Jacques H. A review of studies concerning effects of sleep deprivation and fatigue on residents' performance. Acad Med 66 (1991) 687-693
130. Papp K., Stoller E., Sage P., et al. The effects of sleep loss and fatigue on resident-physicians. a multi-institutional, mixed-method study. Acad Med 79 (2004) 394-406
131. Deaconson T., O'Hair D., Levy M., et al. Sleep deprivation and resident performance. JAMA 260 (1988) 1721-1727
132. Boodman S. Limited experience, high expectations (2001) Washington Post, March, p H01
133. Veasey S., Rosen R., Barzansky B., et al. Sleep loss and fatigue in resident training. JAMA 288 (2002) 1116-1124
134. Haynes D., Schwedler M., Dyslin D., et al. Are postoperative complications related to resident sleep deprivation?. South Med J 88 (1995) 283-289
135. Uchal M., Tjugum J., Martinsen E., et al. The impact of sleep deprivation on product quality and procedure effectiveness in a laparoscopic physical simulator. a randomized controlled trial. Am J Surg 189 (2005) 753-757
136. Taffinder N., McManus R., Jansen J., et al. An objective assessment of surgeons' psychomotor skills. validation of the MIST-VR laparoscopic simulator. Br J Surg 85 (1998) 75
137. Taffinder N., McManus C., Gul Y., et al. Effect of sleep deprivation on surgeons' dexterity on laparoscopic simulator. Lancet 352 (1998) 1191
138. Grantcharov T., Bardram L., Funch-Jensen P., et al. Laparoscopic performance after one night on call in a surgical department. prospective study. Br Med J 323 (2001) 1222-1223
139. Warltier D., Howard S., Rosekind M., et al. Fatigue in anesthesia. implications and strategies for patient and provider safety. Anesthesiology 97 (2002) 1281-1294
140. Reinertsen J. Zen and the art of physician autonomy maintenance. Ann Intern Med 138 (2003) 992-995
141. Kubler-Ross E. On death and dying (1997), Simon & Schuster, New York
142. Barone J., and Ivy M. Resident work hours. the five stages of grief. Acad Med 79 (2004) 379-380
143. Bosk C. Forgive and remember (1979), The University of Chicago Press, Chicago
144. Alcoholics Anonymous World Services. Twelve steps and twelve traditions. New York: Alcoholics Anonymous World Services, Inc; 1953 and 1994.
145. Gordon L. Gordon's guide to the surgical morbidity and mortality conference (1994), Elsevier Inc, New York
146. Andrus C., Villasenor E., Kettelle J., et al. "To err is human". uniformly reporting medical errors and near misses, a naïve, costly, and misdirected goal. J Am Coll Surg 196 (2003) 911-918
147. Altschuler E.L. Prospective randomised trial of sleep deprived versus rested surgeons. Lancet 353 (1999) 501
148. Wolfe T. The right stuff (1979), Straus & Giroux, Inc, New York Bantam Books/published by arrangement with Farrar
149. Lockley S., Cronin J., Evans E., et al. Effect of reducing interns' weekly work hours on sleep and attentional failures. N Engl J Med 351 (2004) 1829-1836
150. Landrigan C., Rothschild J., Cronin J., et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 351 (2004) 1838-1848
151. Barger L., Cade B., Ayas N., et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med 352 (2005) 125-134
152. Petersen L., Brennan T., O'Neil A., et al. Does housestaff discontinuity of care increase the risk for preventable adverse events?. Ann Intern Med 121 (1994) 866-872
153. Fletcher K., Saint S., and Mangrulkar R. Balancing continuity of care with residents' limited work hours. defining the implications. Acad Med 80 (2005) 39-43
154. Drazen J. Awake and informed. N Engl J Med 351 (2004) 1884
155. Richardson J., and Bland K. Learning to operate in a restricted duty hours environment. Am J Surg 190 (2005) 354-355
156. Karamanoukian R.F., Ku J.K., DeLaRose J., et al. The effects of restricted work hours on clinical training. Am Surg 72 (2006) 19-21
157. Marcus C., and Loughlin G. Effect of sleep deprivation on driving safety in housestaff. Sleep 19 (1996) 763-766
158. Wendt J., and Yen L. The resident by moonlight. a misguided missile. JAMA 259 (1988) 43-44
159. Brick J.F., and Brick J.E. Moonlighter takes on airs. rehydration, aeration, obtundation, and education. JAMA 258 (1987) 1475
160. Spencer A., and Teitelbaum D. Impact of work-hour restrictions on residents' operative volume on a subspecialty surgical service. J Am Coll Surg 200 (2005) 670-676
161. Borenstein S., Choi M., Gerstle J., et al. Errors and adverse outcomes on a surgical service. what is the role of residents?. J Surg Res 122 (2004) 162-166
162. Kaafarani H., Itani K., Petersen L., et al. Does resident hours reduction have an impact on surgical outcomes?. J Surg Res 126 (2005) 167-171
163. Schenarts P., Bowen J., Bard M., et al. The effect of a rotating night-float coverage scheme on preventable and potentially preventable morbidity at a level 1 trauma center. Am J Surg 190 (2005) 147-152
164. Poulose B., Ray W., Arbogast P., et al. Resident work hour limits and patient safety. Ann Surg 241 (2005) 847-860
165. McElearney S., Saalwachter A., Hedrick T., et al. Effect of the 80-hour work week on cases performed by general surgery residents. Am Surg 71 (2005) 552-556
166. Mendoza K., and Britt L.D. Resident operative experience during the transition to work-hour reform. Arch Surg 140 (2005) 137-145
167. Bland K., Stoll D., Richardson J., et al. Brief communication of the residency review committee-surgery (RRC-S) on residents' surgical volume in general surgery. Am J Surg 190 (2005) 345-350
168. Feanny M.A., Scott B.G., Mattox K.A., et al. Impact of the 80-hour workweek on residency emergent operative experience. Am J Surg 190 (2005) 947-949
169. Niederee M., Knudtson J., Byrnes M., et al. A survey of residents and faculty regarding work hour limitations in surgical training programs. Arch Surg 138 (2003) 663-671
170. Gelfand D., Podnos Y., Carmichael J., et al. Effect of the 80-hour workweek on resident burnout. Arch Surg 139 (2004) 933-940
171. Meyer A., and Weiner T. The generation gap. Arch Surg 137 (2002) 268-270
172. Leibrandt T.L., Pezzi C.M., Fassler S.A., et al. Has the 80-hour workweek had an impact on voluntary attrition in general surgical residency programs?. J Am Coll Surg 202 (2006) 340-344
173. Whang E., Perez A., Ito H., et al. Work hours reform. perceptions and desires of contemporary surgical residents. J Am Coll Surg 197 (2003) 624-630
174. Whang E., Mello M., Ashley S., et al. Implementing resident work hour limitations. Ann Surg 237 (2003) 449-455
175. Coverdill J.E., Adrales G.L., Finlay W., et al. How faculty and residents assess the first year of the accreditation council for graduate medical education duty-hour restrictions. results of a multi-institutional study. Am J Surg 191 (2006) 11-16
176. Fischer J. On the uniqueness of surgery. Am J Surg 189 (2005) 259-263
177. Gallagher S., Ross S., Haines K., et al. Realistic expectations and leadership in the era of work hour reform. J Surg Res 126 (2005) 137-144
178. Richardson D. Presidential address. the current status of academic surgery departments in the south. Ann Surg 239 (2004) 575-587
179. Harder F. "I would like to be a surgeon, but . . . .". Ann Surg 236 (2002) 699-702
180. Victorino G., and Organ C. Physician assistant influence on surgery residents. Arch Surg 138 (2003) 971-976
181. Chung R. How much time do surgical residents need to learn operative surgery?. Am J Surg 190 (2005) 351-353
182. Grogan E. Should I lie about my work hours this week?. J Am Coll Surg 200 (2005) 635-637
183. Carpenter R., Austin M., Tarpley J., et al. Work-hour restrictions as an ethical dilemma for residents. Am J Surg 191 (2006) 527-532
184. Anderson H.C. The emperor's new clothes (2002), North South Books, New York
185. Weigelt J. Medical education crisis. not just an issue of work hours. Arch Surg 138 (2003) 1027-1028
186. Silen W. Crisis in surgical education. J Am Coll Surg 193 (2001) 514-515
187. Weber S., Fergestad J., Lewis B., et al. How should medical student surgical rotations be structured to optimize education?. J Surg Res 126 (2005) 145-148
188. Shackford S. How then shall we change. J Trauma 60 (2006) 1-7