title: How do surgical residents and non-physician practitioners play together in the sandbox?
abstract: BACKGROUND
  The reduction of resident work hours due to the 80-hour workweek has created pressure on academic health-care systems to find "replacement residents." At the authors' institution, a group of nurse practitioners (NPs) and physician assistants (PAs), collectively referred to as non-physician practitioners (NPPs), were hired as these reinforcements, such that the number of NPPs (56) was almost twice the number of clinical categorical surgery residents (37). An experienced leader with national credibility was hired to run the NPP program. On each service, the call system was changed to a night float system, whereby residents were pulled from traditional resident teams to serve as nighttime residents during the week. A total of 1-3 NPPs were hired for each team, but whether NPPs worked for the team as a whole, or were assigned to individual attendings, was left to the discretion of the division chiefs. One year after the start of this program, the authors wanted to study the effects it has had on both surgery resident education and NPP job satisfaction.
  
  
  METHODS
  An electronic, anonymous survey was conducted during a monthly surgery resident meeting, and out of 72 categorical and preliminary surgery residents, 50% submitted answers to 12 questions. A similar electronic survey was administered to all 56 NPPs, with 45% responding.
  
  
  RESULTS
  Overall, 63% of residents believed that lines of communication between surgery team members were clear, and 58% of residents and 71% of NPPs believed that attendings, residents, and NPPs worked together effectively. A total of 91% of residents believed that the addition of NPPs to the teams was positive overall, and 80% of NPPs were satisfied with their positions. Overall, 60% of residents and 50% of NPPs felt that educational goals were being met.
  
  
  CONCLUSIONS
  Implementation of the 80-hour workweek and introduction of NPs and PAs onto the inpatient surgical services has altered resident education at the authors' institution. Although overall most residents view the addition of NPPs to the clinical services as positive, there are concerns about the program. Although hired to fill the void left by decreasing labor hours of residents, NPPs do not necessarily have the same goals as surgery residents and there is confusion about how NPPs fit into the hierarchy of the traditional surgical team.
authors.affiliation: Surgery Education, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Andrew S
authors.initials: AS
authors.lastname: Resnick
authors.forename: Barbara A
authors.initials: BA
authors.lastname: Todd
authors.forename: James L
authors.initials: JL
authors.lastname: Mullen
authors.forename: Jon B
authors.initials: JB
authors.lastname: Morris
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D001291:Attitude of Health Personnel; D002983:Clinical Competence; D005260:Female; D013502:General Surgery / Q000193:education*; D019538:Health Care Surveys; D006785:Hospitals, University; D006801:Humans; D007396:Internship and Residency; D007400:Interprofessional Relations; D008297:Male; D008875:Middle Aged; D009722:Nurse Practitioners / Q000523:psychology; D010348:Patient Care Team; D010414:Pennsylvania; D010823:Physician Assistants / Q000523:psychology; D017009:Professional Autonomy; D011787:Quality of Health Care; D014940:Work Schedule Tolerance; D000078329:Workforce; D016526:Workload