Effects of 24-hour versus night-float call schedules on the clinical and operative experiences of postgraduate year 2 and 3 neurosurgical residents

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  • 1 Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
  • | 2 Department of Neurosurgery, Stanford University, Palo Alto, California
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OBJECTIVE

To comply with the removal of the 88-hour week exemption and to support additional operative experience during junior residency, Oregon Health & Science University (OHSU) switched from a night-float call schedule to a modified 24-hour call schedule on July 1, 2019. This study compared the volumes of clinical, procedural, and operative cases experienced by postgraduate year 2 (PGY-2) and PGY-3 residents under these systems.

METHODS

The authors retrospectively studied billing and related clinical records, call schedules, and Accreditation Council for Graduate Medical Education case logs for PGY-2 and PGY-3 residents at OHSU, a tertiary academic health center, for the first 4 months of the academic years from 2017 to 2020. The authors analyzed the volumes of new patient consultations, bedside procedures, and operative procedures performed by each PGY-2 and PGY-3 resident during these years, comparing the volumes experienced under each call system.

RESULTS

Changing from a PGY-2 resident–focused night-float call system to a 24-hour call system that was more evenly distributed between PGY-2 and PGY-3 residents resulted in decreased volume of new patient consultations, increased volume of operative procedures, and no change in volume of bedside procedures for PGY-2 residents. PGY-3 residents experienced a decrease in operative procedure volume under the 24-hour call system.

CONCLUSIONS

Transition from a night-float system to a 24-hour call system altered the distribution of clinical and procedural experiences between PGY-2 and PGY-3 residents. Further research is necessary to understand the impact of these changes on educational outcomes, quality and safety of patient care, and resident satisfaction.

ABBREVIATIONS

ACGME = Accreditation Council for Graduate Medical Education; OHSU = Oregon Health & Science University; PGY = postgraduate year; VA = Veterans Affairs.

OBJECTIVE

To comply with the removal of the 88-hour week exemption and to support additional operative experience during junior residency, Oregon Health & Science University (OHSU) switched from a night-float call schedule to a modified 24-hour call schedule on July 1, 2019. This study compared the volumes of clinical, procedural, and operative cases experienced by postgraduate year 2 (PGY-2) and PGY-3 residents under these systems.

METHODS

The authors retrospectively studied billing and related clinical records, call schedules, and Accreditation Council for Graduate Medical Education case logs for PGY-2 and PGY-3 residents at OHSU, a tertiary academic health center, for the first 4 months of the academic years from 2017 to 2020. The authors analyzed the volumes of new patient consultations, bedside procedures, and operative procedures performed by each PGY-2 and PGY-3 resident during these years, comparing the volumes experienced under each call system.

RESULTS

Changing from a PGY-2 resident–focused night-float call system to a 24-hour call system that was more evenly distributed between PGY-2 and PGY-3 residents resulted in decreased volume of new patient consultations, increased volume of operative procedures, and no change in volume of bedside procedures for PGY-2 residents. PGY-3 residents experienced a decrease in operative procedure volume under the 24-hour call system.

CONCLUSIONS

Transition from a night-float system to a 24-hour call system altered the distribution of clinical and procedural experiences between PGY-2 and PGY-3 residents. Further research is necessary to understand the impact of these changes on educational outcomes, quality and safety of patient care, and resident satisfaction.

Attempts to optimize neurosurgical residents’ clinical experiences in the face of progressively restrictive duty-hour limitations requires innovation and iteration in the design of resident call schedules. The Accreditation Council for Graduate Medical Education’s (ACGME) duty-hour limitation revisions in 2003 and 2011 caused many programs to modify duty-hour and call schedules while evaluating residents’ clinical, procedural, and operative experiences.1 The neurological surgery program at Oregon Health & Science University (OHSU) reported one such change—a shift to a night-float schedule that reduced duty-hour violations while maintaining resident case numbers.2 To comply with removal of the 88-hour week exemption and to support additional operative experience during junior residency, OHSU reinstituted a modified version of a 24-hour call schedule on July 1, 2019.

According to various reports, transitioning to or from night-float and 24-hour call systems increased operative case numbers without changing inpatient mortality indices.37 Switching to a night-float system at OHSU also reduced duty-hour violations,2 but this finding has not been replicated. Transitions to either system have garnered strong support among residents at various individual programs.2,4,6,8,9 Data comparing the effects of these schedules on resident call–related workload are notably lacking, with details of on-call workload systematically reported for only a single resident.1

The first months of junior neurosurgery residency present a unique challenge after what is, at our program, a relatively more generalized clinical internship with rotations in neurology, anesthesia, trauma critical care, and otolaryngology. Residents are required to optimize personal workflows, improve efficiency at managing a wide array of pathologies, and advance independence in performing bedside procedures, while also coping with lengthier on-call duty schedules. Development of these core call-related clinical skills competes with scheduled exposure to elective operative cases. In this study, we sought to determine the effects of workload redistribution after switching from a night-float system to a 24-hour call system with particular attention to new patient evaluations, bedside procedures, and operative cases that are central to junior resident education.

Methods

Study Setting

We performed a retrospective review of departmental billing records and ACGME case logs of junior neurosurgery residents at OHSU, a tertiary-care academic medical center in Portland, Oregon, from July 1 to November 1 of each year from 2017 to 2020. The residency program was divided into 4 clinical services (university A and B, pediatric, and Veterans Affairs [VA]) during the study period. These services have a cumulative average inpatient census of 50 to 60 patients.

The program had just completed a transition from alternating classes of 2 and 3 residents to 3 residents per year. All 4 classes of postgraduate year 2 (PGY-2) residents had 3 residents each. The local IRB approved data collection for this study.

Call Schedule Change and Resident Responsibilities

Under the night-float system, PGY-2 residents rotated through 2-week periods of 14-hour “day-float” and “night-float” call and 2 weeks in the operating room. Generally, residents did not go to the operating room while on call. PGY-2 through PGY-4 residents provided weekend coverage under the 24-hour system (Fig. 1). Daytime workload was divided as follows. The day-float PGY-2 resident oversaw the university services’ censuses and emergency department consultations (adult and pediatric). The PGY-3 resident at Doernbecher Children’s Hospital oversaw the pediatric service’s census. The PGY-3 resident at the VA managed that census and saw consultations at the VA. At night, PGY-2 (during weeknights) and PGY-3 or PGY-4 (weekends) residents covered all nonoperative responsibilities at all 3 hospitals. One resident from this pool provided 24-hour coverage on Saturdays.

FIG. 1.
FIG. 1.

Sample call schedules under the night-float system (July 2018) and the 24-hour call system (July 2019).

The schedule transitioned to a rotating 24-hour call system on July 1, 2019, to accommodate the new 80-hour duty-hour restrictions and to increase PGY-2 residents’ operative exposure. Daytime workload was divided between residents in the same way, but the university call was rotated between PGY-2 residents every other day (Fig. 1). Nighttime coverage at all hospitals was provided by either the daytime PGY-2 resident completing a 24-hour shift or by a PGY-3 resident. Both Saturday and Sunday were covered with 24-hour shifts.

Balancing Call and Operating Room Experience

Call schedules were reviewed for the study period. The number of day, night, and 24-hour call shifts were recorded for each resident. To best compare the proportions of day to night calls between cohorts, 24-hour shifts were recorded as one 14-hour day plus one 14-hour night.

Resident operating room experience was measured in two overlapping ways to account for time spent in the clinic rather than the operating room, which can vary between services. The number of potential operative days (i.e., all weekdays excluding postcall days) were recorded for PGY-2 residents and nonresearch PGY-3 residents and normalized to per-month values.

The web-based ACGME case log system was queried for all logged procedures during the same period for each resident, and the number of operative cases was extracted. Case numbers were normalized to per-month values and compared between the night-float and 24-hour cohorts.

New Patient Evaluation and Bedside Procedure Distribution

On-call resident workload was determined from consult, admission, and procedure notes obtained from the departmental billing records. Electronic medical record review confirmed appropriate attribution of the note to the resident author. Consult and admission notes were tallied for each PGY-2 class and the PGY-3/4 cohorts who also took in-house calls. Common bedside procedures were aggregated by type—placement of an external ventricular drain, intracranial pressure monitor, lumbar puncture, lumbar drain, or shunt tap—in a similar fashion.

Resident Satisfaction

A daily survey of on-call residents was attempted at the beginning of the study period. Compliance with the questionnaire was poor, so we retrieved the results from the ACGME Annual Program and Well-Being Surveys that were administered before and after the schedule change. Data were retrospectively and qualitatively compared because ACGME expressly forbids publication of individual program survey data.

Data Analysis

All group data were presented as median ± interquartile range unless otherwise specified. Between-group comparisons of the proportions of call shifts, new patient evaluations, and bedside procedures were made using chi-square analysis. Between-group comparisons of operative days and operative case volume were made using the Mann-Whitney test. Between-group comparisons of specific bedside procedures were performed using multiple Mann-Whitney tests with the 2-stage Benjamini, Krieger, and Yekutieli procedure to control the false discovery rate. In this study, p < 0.05 was considered statistically significant. Statistical analysis was performed using GraphPad Prism 9.3.

Results

The Rotating 24-Hour Call Schedule Redistributed Call and Operative Experience

After removal of the 88-hour exemption, the 24-hour call system complied with the new 80-hour work restrictions and resulted in a substantial redistribution of call burden. PGY-3 residents took a greater share of total call under the new system (16.6% of all call was taken by PGY-3 residents under the night-float system vs 31.4% under the 24-hour system, p < 0.0001) (Table 1), predominantly due to an increase from 16.8% to 48.8% of nighttime call. The share of daytime call handled by PGY-2 residents remained similar (83.7% vs 86.1% of daytime call).

TABLE 1.

Distribution of call shifts, July 1 to November 1, 2017–2020

ScheduleTotal CallDay CallNight Call
Night float
 PGY-2408 (83)210 (84)198 (83)
 PGY-3/481 (17)41 (16)40 (17)
24 hr
 PGY-2337 (69)211 (86)126 (51)
 PGY-3154 (31)34 (14)120 (49)

All values are shown as number (%).

The median number of potential operative days for PGY-2 residents increased from 6 to 10 days per month (p = 0.002) (Fig. 2A). In contrast, pediatric (n = 4) and VA (n = 3) PGY-3 residents had a median 3.5 fewer operative days per month under the 24-hour call system (p = 0.057). Accordingly, median PGY-2 operative case numbers increased from 8 to 11.25 per month after the transition (p = 0.009), whereas operative cases for PGY-3 residents decreased from 15.6 to 10.7 cases per month (p = 0.345) (Fig. 2B).

FIG. 2.
FIG. 2.

Enhanced operative experience of PGY-2 residents when our institution switched from the night-float to 24-hour call system. A: The median number of potential operative days increased for PGY-2 residents (p = 0.002) and decreased for PGY-3 residents (p = 0.057). B: An increased median number of surgical cases was performed by PGY-2 residents under the 24-hour call system compared with the night-float system (p = 0.009), with no significant changes in cases performed by PGY-3 residents (p = 0.345). Error bars indicate SD. ns = nonsignificant. *p < 0.05.

Consult Workload, but not Procedure Volume, Was Redistributed Under the 24-Hour Call System

The proportion of new patient evaluations by PGY-2 residents significantly decreased from the night-float to 24-hour call system (82.2% vs 63%, p < 0.0001) (Fig. 3A), with a compensatory increase in the proportion of evaluations by PGY-3 or PGY-4 residents (17.8% to 35%). In total, the average number of consults seen per month over the 4-month study period decreased slightly from 2017–2018 to 2019–2020 (244.6 under the night-float system to 234.3 under the 24-hour system).

FIG. 3.
FIG. 3.

Workload redistribution from the night-float to 24-hour call system. PGY-2 residents saw a significantly lower proportion of consults under the 24-hour call system (p < 0.001) (A), but there was no significant difference in the proportions of bedside procedures performed during the study period (p = 0.178) (B). Error bars indicate SD.

In contrast, the proportion of total bedside procedures performed by PGY-2 residents did not change (82.9% to 75.0%, p = 0.178) (Fig. 3B). This effect was true for all types of bedside procedures (Fig. 4). The average number of bedside procedures per month over the 4-month study also remained similar between 2017–2018 and 2019–2020 (52.3 under the night-float system vs 51 under the 24-hour system).

FIG. 4.
FIG. 4.

Median bedside procedure counts were similar between the night-float and 24-hour schedules. Bolt = intracranial pressure monitor; EVD = external ventricular drain; LD = lumbar drain; LP = lumbar puncture. Error bars indicate SD.

ACGME Survey Scores Were Unchanged or Improved Under the 24-Hour Call System

The ACGME Annual and Well-Being Survey results were retrieved for 2018 (night-float system) and 2021 (24-hour call system). These results showed substantial improvements in compliance with weekly duty-hour limits (80- or 88-hour work weeks) and scheduling 24 or fewer consecutive work hours. Scores from overlapping questions on the Well-Being Survey varied somewhat between years, but there was no obvious trend in overall well-being scores, with almost identical average scores for comparable questions noted between survey years (data not shown).

Discussion

Call schedules are a common target of quality improvement efforts in residency curriculum design. In surgical specialties, most adaptations have sought to optimize resident operative experience in the face of progressively restrictive duty-hour limits.27 Our program recently transitioned from a night-float to a 24-hour call schedule by assigning a greater share of overnight call duties to PGY-3 residents. We sought to quantify the effects of this change on formative junior resident clinical experiences both inside and, in the first report to our knowledge, outside of the operating room. These data may serve as a baseline against which to compare future duty schedule innovations.

PGY-2 residents performed significantly fewer new patient evaluations in their first 4 months participating in the 24-hour call system compared with the night-float system. At face value, this reduced volume of patient consultations prolongs the learning curve for early junior residents by slowing specialized skill development. The general trend across programs toward greater time spent with the neurosurgery service during internship may smooth this transition more than in the past, but it remains a significant escalation in responsibility within our program’s curriculum. Managing large inpatient censuses with high acuity demands efficient personal workflows, risk triage, knowledge of a wide array of pathologies, and procedural skill. Objectively measuring the effects of changes in volume and timing of clinical experience on educational outcomes is a difficult but very important goal for future studies.

Unlike new patient evaluations, there was no significant change in PGY-2 bedside procedural experience after the transition to a 24-hour call schedule. We did not study the timing at which bedside procedures were performed in this or the previous study of the night-float system at our institution.2 In the only study to examine this to date—a single junior resident’s call log from a different institution—a significantly higher proportion of bedside procedures was performed during the daytime.1 At OHSU, PGY-2 residents took similar proportions of the daytime call under the 24-hour and night-float call systems, possibly accounting for the unchanged procedural volumes between the two systems.

Transition to the 24-hour call system at OHSU was intended to improve the volume of operative procedural experience for PGY-2 residents. Under the night-float call schedule, PGY-2 residents were in the operating room for 2 weeks of each 6-week block and took day- and night-float call for the remaining 4 weeks. Under the 24-hour call schedule, operative experience was more frequent for PGY-2 residents and often included multiple days per week in the operating room. This was enabled by PGY-3 residents taking a greater share of the nighttime call, but unfortunately this came at the expense of their operative experience, with a decrease in potential operative days. However, a key advantage of the 24-hour call system is that both PGY-2 and PGY-3 residents have consistently distributed operative training. Robust evidence supports the effectiveness of distributed practice in motor skill acquisition.10,11 The magnitude of this beneficial effect depends on training context and task complexity,12 and it has never been directly studied in neurosurgical training. Even so, most studies of laparoscopic and microvascular anastomosis demonstrate greater proficiency and skill retention with spaced training sessions—similar to those now experienced by OHSU neurosurgery residents who work under the 24-hour call schedule.1216 Appropriately distributing clinical practice experiences during neurosurgery training may similarly maximize training efficiency and effectiveness.

The call schedule alteration had effects beyond those directly related to resident workload and education. For example, the 24-hour schedule resulted in postcall weekdays that were free of clinical duties, allowing residents to rest, attend personal healthcare appointments, or participate in other wellness activities. Furthermore, the 24-hour call schedule was partially responsible for shifting PGY-4 residents to home call, thereby improving their work-life balance and allowing them to develop the skills necessary for this important clinical function that is central to independent practice.

Reducing the frequency of patient care handoffs improves care quality and reduces medical errors.17,18 Transition to a modified 24-hour call schedule, as reported here, reduced the frequency of handoffs from an average of 2 to 1.5 per day, while simultaneously necessitating increased cross-coverage between services by PGY-3 residents who were uninvolved in the direct care of patients at the primary university service. The effects of these changes on patient care quality, if any, were not measured and are beyond the scope of the present study, but these are an important topic for additional research.

This study has several limitations. It is the product of a 4-year experience at a single academic center with a relatively small number of residents, limiting its generalizability. Resident well-being and satisfaction with either call schedule was not rigorously studied before or after the scheduling change. A daily quality-of-life survey was administered to all on-call residents after the transition to the 24-hour call system, but it was abandoned due to poor compliance and the lack of any comparison data from the night-float cohorts. The results from the ACGME Well-Being Surveys administered before and after the scheduling change suggest no significant impact on resident wellness, but these data were compiled across the entire resident cohort and subject to many other factors. We plan to investigate quality-of-life measures with greater scrutiny after future call schedule changes. Lastly, the COVID-19 pandemic affected our case volume and inpatient censuses in the fall of 2020, partially confounding comparisons with other years. However, PGY-2 residents from that year performed the same number of procedures and had higher case numbers than any year before, suggesting that the benefits of the curriculum design change persisted despite negative effects on clinical volume due to COVID-19.

Conclusions

Transitioning from a night-float to 24-hour call schedule reduced the volume of patient consultations by PGY-2 residents, but not their procedural experience. PGY-2 residents experienced an increase in operative procedural experience at the expense of PGY-3 residents under the 24-hour call schedule. These data may serve as a baseline by which to evaluate the impact of any future call schedule innovations. Future research should also investigate the impact of call schedule changes on patient care quality and educational outcomes.

Acknowledgments

We thank Michael McGehee for his laborious vetting of departmental records and Dr. Thomas Sutton for his statistical advice.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Selden, Bowden, Siler, Mazur-Hart, Munger, Ross, Rothbaum, Han, Wright, Orina, Winer. Acquisition of data: Bowden, Siler, Shahin, Mazur-Hart, Munger, Ross, O’Neill, Nerison, Rothbaum. Analysis and interpretation of data: Selden, Bowden, Siler, Shahin, Mazur-Hart, Munger, Ross, O’Neill, Han, Wright, Orina, Winer. Drafting the article: Bowden, Siler, Nerison, Orina. Critically revising the article: Selden, Bowden, Shahin, Mazur-Hart, Ross, Han, Wright, Orina, Winer. Reviewed submitted version of manuscript: all authors. Statistical analysis: Bowden, Siler, Munger, O’Neill. Administrative/technical/material support: Bowden. Study supervision: Bowden.

Supplemental Information

Previous Presentations

Some findings from this study were presented virtually in the form of an electronic poster at the American Association of Neurological Surgeons Annual Meeting, Orlando, FL, August 2021.

References

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    Gordon WE, Gienapp AJ, Jones M, Michael LM, Klimo P. An analysis of the on-call clinical experience of a junior neurosurgical resident. Neurosurgery. 2019;85(2):290297.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Ragel BT, Piedra M, Klimo P, et al. An ACGME duty hour compliant 3-person night float system for neurological surgery residency programs. J Grad Med Educ. 2014;6(2):315319.

    • Crossref
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  • 3

    McGahan BG, Hatef J, Shaikhouni A, et al. Resident night float or 24-hour call hospital coverage: impact on training, patient outcome, and length of stay. J Surg Educ. 2022;79(3):732739.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Scott JK, Bhattacharya SD, Giles WH. Comparison of operative experiences of PGY-1 and PGY-2 general surgery residents during night-float vs. 24-hour call systems. J Surg Educ. 2021;78(6):e56e61.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Healy JM, Maxfield MW, Solomon DG, Longo WE, Yoo PS. Beyond 250: a comprehensive strategy to maximize the operative experience for junior residents. J Surg Educ. 2018;75(3):541545.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Davis MC, Kuhn EN, Agee BS, Oster RA, Markert JM. Implications of transitioning to a resident night float system in neurosurgery: mortality, length of stay, and resident experience. J Neurosurg. 2017;126(4):12691277.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Scally CP, Reames BN, Teman NR, Fritze DM, Minter RM, Gauger PG. Preserving operative volume in the setting of the 2011 ACGME duty hour regulations. J Surg Educ. 2014;71(4):580586.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    Sterling L, McCaffrey C, Secter M, et al. Development of a night float call model for obstetrics and gynaecology residency: the process and residents’ perceptions. J Obstet Gynaecol Can. 2016;38(11):10611064.e1.

    • Crossref
    • Search Google Scholar
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  • 9

    Shirreff L, Shapiro JL, Yudin MH. Perceptions of a night float system of resident call within an obstetrics and gynaecology residency training program. J Obstet Gynaecol Can. 2014;36(11):957961.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Rosenbaum DA, Carlson RA, Gilmore RO. Acquisition of intellectual and perceptual-motor skills. Annu Rev Psychol. 2001;52:453470.

  • 11

    Lee TD, Genovese ED. Distribution of practice in motor skill acquisition: different effects for discrete and continuous tasks. Res Q Exerc Sport. 1989;60(1):5965.

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  • 12

    Spruit EN, Band GP, Hamming JF. Increasing efficiency of surgical training: effects of spacing practice on skill acquisition and retention in laparoscopy training. Surg Endosc. 2015;29(8):22352243.

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  • 13

    Ritter FE, Yeh MK, Yan Y, Siu KC, Oleynikov D. Effects of varied surgical simulation training schedules on motor-skill acquisition. Surg Innov. 2020;27(1):6880.

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    • Export Citation
  • 14

    Mackay S, Morgan P, Datta V, Chang A, Darzi A. Practice distribution in procedural skills training: a randomized controlled trial. Surg Endosc. 2002;16(6):957961.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15

    Moulton CA, Dubrowski A, Macrae H, Graham B, Grober E, Reznick R. Teaching surgical skills: what kind of practice makes perfect?: a randomized, controlled trial. Ann Surg. 2006;244(3):400409.

    • Crossref
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  • 16

    Gallagher AG, Jordan-Black JA, O’Sullivan GC. Prospective, randomized assessment of the acquisition, maintenance, and loss of laparoscopic skills. Ann Surg. 2012;256(2):387393.

    • Crossref
    • Search Google Scholar
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  • 17

    Wolinska JM, Lapidus-Krol E, Fallon EM, Kolivoshka Y, Fecteau A. I-PASS enhances effectiveness and accuracy of hand-off for pediatric general surgery patients. J Pediatr Surg. 2022;57(4):598603.

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  • 18

    Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371(19):18031812.

  • View in gallery

    Sample call schedules under the night-float system (July 2018) and the 24-hour call system (July 2019).

  • View in gallery

    Enhanced operative experience of PGY-2 residents when our institution switched from the night-float to 24-hour call system. A: The median number of potential operative days increased for PGY-2 residents (p = 0.002) and decreased for PGY-3 residents (p = 0.057). B: An increased median number of surgical cases was performed by PGY-2 residents under the 24-hour call system compared with the night-float system (p = 0.009), with no significant changes in cases performed by PGY-3 residents (p = 0.345). Error bars indicate SD. ns = nonsignificant. *p < 0.05.

  • View in gallery

    Workload redistribution from the night-float to 24-hour call system. PGY-2 residents saw a significantly lower proportion of consults under the 24-hour call system (p < 0.001) (A), but there was no significant difference in the proportions of bedside procedures performed during the study period (p = 0.178) (B). Error bars indicate SD.

  • View in gallery

    Median bedside procedure counts were similar between the night-float and 24-hour schedules. Bolt = intracranial pressure monitor; EVD = external ventricular drain; LD = lumbar drain; LP = lumbar puncture. Error bars indicate SD.

  • 1

    Gordon WE, Gienapp AJ, Jones M, Michael LM, Klimo P. An analysis of the on-call clinical experience of a junior neurosurgical resident. Neurosurgery. 2019;85(2):290297.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Ragel BT, Piedra M, Klimo P, et al. An ACGME duty hour compliant 3-person night float system for neurological surgery residency programs. J Grad Med Educ. 2014;6(2):315319.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3

    McGahan BG, Hatef J, Shaikhouni A, et al. Resident night float or 24-hour call hospital coverage: impact on training, patient outcome, and length of stay. J Surg Educ. 2022;79(3):732739.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Scott JK, Bhattacharya SD, Giles WH. Comparison of operative experiences of PGY-1 and PGY-2 general surgery residents during night-float vs. 24-hour call systems. J Surg Educ. 2021;78(6):e56e61.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Healy JM, Maxfield MW, Solomon DG, Longo WE, Yoo PS. Beyond 250: a comprehensive strategy to maximize the operative experience for junior residents. J Surg Educ. 2018;75(3):541545.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Davis MC, Kuhn EN, Agee BS, Oster RA, Markert JM. Implications of transitioning to a resident night float system in neurosurgery: mortality, length of stay, and resident experience. J Neurosurg. 2017;126(4):12691277.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Scally CP, Reames BN, Teman NR, Fritze DM, Minter RM, Gauger PG. Preserving operative volume in the setting of the 2011 ACGME duty hour regulations. J Surg Educ. 2014;71(4):580586.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    Sterling L, McCaffrey C, Secter M, et al. Development of a night float call model for obstetrics and gynaecology residency: the process and residents’ perceptions. J Obstet Gynaecol Can. 2016;38(11):10611064.e1.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Shirreff L, Shapiro JL, Yudin MH. Perceptions of a night float system of resident call within an obstetrics and gynaecology residency training program. J Obstet Gynaecol Can. 2014;36(11):957961.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Rosenbaum DA, Carlson RA, Gilmore RO. Acquisition of intellectual and perceptual-motor skills. Annu Rev Psychol. 2001;52:453470.

  • 11

    Lee TD, Genovese ED. Distribution of practice in motor skill acquisition: different effects for discrete and continuous tasks. Res Q Exerc Sport. 1989;60(1):5965.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Spruit EN, Band GP, Hamming JF. Increasing efficiency of surgical training: effects of spacing practice on skill acquisition and retention in laparoscopy training. Surg Endosc. 2015;29(8):22352243.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Ritter FE, Yeh MK, Yan Y, Siu KC, Oleynikov D. Effects of varied surgical simulation training schedules on motor-skill acquisition. Surg Innov. 2020;27(1):6880.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Mackay S, Morgan P, Datta V, Chang A, Darzi A. Practice distribution in procedural skills training: a randomized controlled trial. Surg Endosc. 2002;16(6):957961.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15

    Moulton CA, Dubrowski A, Macrae H, Graham B, Grober E, Reznick R. Teaching surgical skills: what kind of practice makes perfect?: a randomized, controlled trial. Ann Surg. 2006;244(3):400409.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16

    Gallagher AG, Jordan-Black JA, O’Sullivan GC. Prospective, randomized assessment of the acquisition, maintenance, and loss of laparoscopic skills. Ann Surg. 2012;256(2):387393.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17

    Wolinska JM, Lapidus-Krol E, Fallon EM, Kolivoshka Y, Fecteau A. I-PASS enhances effectiveness and accuracy of hand-off for pediatric general surgery patients. J Pediatr Surg. 2022;57(4):598603.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 18

    Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371(19):18031812.

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