Surgical Education and Resident Work Hours
David Latter
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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.
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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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