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Surgical Education and Resident Work Hours

David Latter
David Latter

In 1984, Libby Zion, an 18-yearold college freshman, was admitted to a New York City hospital with fever and agitation. Seven hours later she was dead. Inquiry into the events of the case demonstrated that her treating physician was a sleep - deprived resident. This was felt to be an important causal factor in this tragedy. The public response was immediate and intense - initiating the move to reform resident work hours.

The first jurisdiction to respond was naturally New York State, which implemented an 80-hour work limit in 1989. It wasn't until 2003 that the Accreditation Council for Graduate Medical Education (ACGME) issued its set of guidelines limiting resident work hours to 80 hours per week. In 2008 the Institute of Medicine issued a report on Resident Duty Hours: Enhancing Sleep, Supervision, and Safety that recommended even more restrictions (1). A subsequent set of ACGME 2010 requirements, which are to go into effect July 2011, have some new restrictions on work hours which will affect surgical education in the US. Some of these requirements include:

  • duty hours limited to 80 hours per week, inclusive of moonlighting.
  • duty hours of PGY-1s are not to exceed 16 continuous hours.
  • PGY-2s and higher are limited to 24 hours of continuous duty.
  • in hospital call not to exceed one in three with averaging.

The American College of Surgeons has issued a response to the new ACGME directives that accepts much of the new ACGME proposal but takes serious issue with the 80-hour minimum and the 16-hour shift for PGY-1s. Their argument is cogent and well worth reviewing (2).

The forces affecting work hours and surgical education in Europe and the UK are even more significant. The 1998 EU Working Time Directive, which took full effect for UK doctors in training in 2009, limits resident work hours to 48 hours per week! Professor John Temple wrote an extensive report called Time for Training that outlines many of the issues and challenges that the United Kingdom medical education enterprise is now dealing with (3).

In Canada resident work hours are mandated by each provincial - resident association agreement. In Ontario we have never had defined total work hours regulations but we do have our own sets of work time provisions. These include:

  • no resident to have 2 consecutive periods of call, unless agreed upon by the resident, the Program Director, and PAIRO.
  • no more than 7 nights of in house call per 28 days.
  • weekend call of no more than 2 days in 8.
  • home call of no more than 1 night in 3.
  • After an in-hospital night of call the resident is to sign over and be relieved of duties by 2 hours post call.

Similar to surgery departments around the world, our Department must address the important issues of how resident working hours relate to patient safety, resident well being, surgical resident education needs, supervision and progressive responsibilities, and workforce issues in teaching hospitals.

As you may recall the University of Toronto Department of Surgery applied for and was granted exemption from the "home by 2 hours post call" provision stipulated in the last PAIRO contract, and maintained the provision of "home by noon post call". This exemption was requested because of our concerns of potential negative education effects if surgical residents are mandated to excuse themselves from the morning elective surgical lists.

There is a growing volume of literature regarding effects of sleep deprivation on cognitive function. It is a reality that cognitive function deteriorates with extended periods without sleep. Some have likened the effect of 24 hours without sleep to having a blood alcohol level of 0.05% (4). Other studies have shown that interns working in the ICU environment made more errors when working frequent shifts of 24 hours than when they worked shorter shifts (5).

Paradoxically, in the United States the predictions that the ACGME policy of 2003 reducing residents work hours would result in improved patient safety outcomes have been hard to validate. Studies have shown mixed results with the majority showing no effect.

Surgical education is significantly different from training in the medical specialties. Our trainees must not only gain the cognitive knowledge of their specialty but also the technical skills. As any sports coach or music teacher knows, technical/manual skills are only learned by repeated practice. Even with maximal use of simulation technologies and skills labs there is no suitable replacement for real life operating room experience. So, it is obvious that at some point if work hours are reduced too much, it will impact on the residents' ability to acquire the required technical skills. I personally believe we are at the tipping point of resident work hours and that any further reduction in work hours will jeopardize resident acquisition of operating room skills.

The Professional Association of Interns and Residents of Ontario (PAIRO) is about to negotiate a new contract, as the current contract ends June 30, 2011. Negotiations for the new contract are set to begin. Unfortunately, when this contract is negotiated there will be no representation from the university at the table to represent the third element of the resident work - hospital service - resident education trilogy.

In September the Royal College hosted a symposium on this subject at its annual International Conference on Residency Education. Following this conference Dr. Andrew Padmos, CEO of The Royal College of Physicians and Surgeons of Canada, signaled that the Royal College intends to look into the resident work hour issue in more depth with a pan Canadian forum (6). As surgical educators, we will participate in this exercise to make sure that our opinion is heard. Our Department will insure that surgery residents' special educational needs are met as Canada moves forward in this discussion.

David Latter

(1) http://www.iom.edu/Reports/2008/Resident-Duty-Hours- Enhancing-Sleep-Supervision-and-Safety.aspx

(2) Bulletin of the American College of Surgeons Vol. 95, No 9, Pages 4-7.

(3) http://www.mee.nhs.uk/PDF/14274%20Bookmark %20 Web%20Version.pdf

(4) Arnedt JT et al. Neurobehavioral performance of residents after heavy night call vs. after alcohol ingestion. JAMA 2005; 294:1025-33.

(5) Landrigan et al. Effects of reducing interns' work hours on serious medical errors in intensive care units. NEJM 2004; 351:1838-48.

(6) http://rcpsc.medical.org/news/newsletters/ ceo_message_ nov10-5_e.html

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