Chair's Column: Resident Duty Hours - Acknowledging the Unique Aspects of Surgical Training
James Rutka
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This past June, the National
Steering Committee on Resident
Duty Hours of the Royal College
of Physicians and Surgeons
(RCPS) produced their report
entitled “Fatigue, Risk, and
Excellence: Towards a Pan-
Canadian Concensus on Resident
Duty Hours. The Committee
should be congratulated for the
breadth and depth of their investigative
inquiry, their review of the literature on resident
duty hours (RDHs), and their ultimate recommendations.
I have followed the RDH dialogue over many years, and of
course with great interest. I have kept abreast of developments
in RDH regulations in the United States as determined
by the Accreditation Council for Graduate Medical
Education (ACGME), and in Europe by the European
Working Time Directive. These jurisdictions have provided
rules and regulations that apply to all residents in
all residency programs without distinction. As a result,
residents in procedural specialties were held to the same
standards as those residents in non-procedural specialties,
and little, if any discussion took place over the unique
needs of a given training program.
Prior to the Royal College Accreditation of our
Residency Programs this past April, and before the RCPS
published its report, I hosted a dinner event to which I
invited the educational directors from some of the procedural
disciplines in the Faculty of Medicine. At the table
were colleagues from Otolaryngology, Anesthesiology,
Obstetrics and Gynecology, Opthalmology, and members
from several of the Divisions in the Department of
Surgery. Accordingly, the stated goals of this working
group meeting were to review the experience of the current
duty hours model across the different procedural disciplines,
and to determine what future models would be
appropriate to train residents in these disciplines to their
maximum potential, and to ensure that resident safety and
restfulness, and patient quality of care were upheld.
Interestingly, in Anesthesiology, hand-over of patients
at the end of a shift was not considered to be an issue, and
some sites had moved to a 16-hour overnight rotation
schedule for residents mimicking what has transpired
for all resident trainees in Quebec. In Ophthalmology,
all resident call is home-call. Emergency call can be very
busy, but calls after midnight are not usually an issue for
opthalmology residents. In Otolaryngology, there are
some very challenging and busy rotations such as the
Head & Neck service at TGH/PMH, but many of the
rotations are set up so the residents can take home-call.
In Obstetrics and Gynecology, a new night float system
was recently established where residents arrive at 6 pm
and leave at 7 am the next day. They do this for a period
of 3 weeks, and during that time, they are not expected
to attend didactic educational activities.
As most of you know, years ago in the Department
of Surgery we applied for and received an exemption
from the PAIRO-based duty hour guidelines in that our
residents work for 24 hr shifts, and are enabled to stay
until 12 noon the next day to hand over ongoing patient
care issues, or to stay for their own educational interests.
We were the only clinical Department in the Province
to request and receive this exemption. In discussion
with our colleagues in the different Divisions of Surgery,
there is no question that our residents are working very
hard, but at the same time, they are advancing in their
skills acquisition, and they have tremendous educational
opportunities across all Divisions, bar none.
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This working group concluded that what is right for
one specialty in terms of RDHs may be inadequate for
another. It was also suggested that residents from the
procedural specialties, such as surgery, should serve on
the decision-making bodies at PAIRO or CAIR so that
optimum training paradigms can be determined for
each. Finally, there was acknowledgement that the concept
of a graded call responsibility may be a good one in
which residents assume more duty hours the farther they
are down the road in their PGY-levels.
I am delighted that the Department of Surgery at
the University of Toronto was more than adequately
represented in the National Steering Committee
working groups. Najma Ahmed (Program Director,
General Surgery) chaired the “Special Considerations
for Procedural Disciplines” work group, and was aided
by Stan Feinberg (General Surgery, NYGH), Abhaya
Kulkarni (Program Director, Neurosurgery), Nir
Lipsman (Resident, Neurosurgery), Todd Mainprize
(Neurosurgery, Sunnybrook), and Jefferson Wilson
(Resident, Neurosurgery). These individuals scoured the
data with respect to duty hours in surgical disciplines,
and provided essential information to the Steering
Committee. In the end, with respect to Surgery, the
National Steering Committee should be commended
for taking into consideration the need for surgical trainees
to acquire procedural skills through repetition and
practice. As mentioned in the report, “there is evidence
to suggest suboptimal patient care and educational outcomes
in surgery resulting from the regulation of duty
hours”. It was acknowledged that delivering emergency
care at unpredictable hours requires technical mastery
and judgement that may only be developed effectively
through time on task. The National Steering Committee
should be lauded for their stance on “a one size does not
fit all” approach to resident education and duty hours.
For her diligent and timely work on the RDH
debate within the National Steering Committee, Najma
received some outstanding publicity in the media appearing
on CTV news (1). In Canada, the regulation of duty
hours is a provincial matter determined by Provincial
Housestaff Organizations. I was very pleased to see the
acknowledgement in the Royal College Report of the
differences in training requirements based on specialty.
To my knowledge, this is the first time that such a distinction
in training and education has been made. For
those of you interested in reading the full report, please
go to: http://www.residentdutyhours.ca
There will unquestionably be some changes in how
RDH are regulated in each of the provinces going forward.
We can, and will do better to aid residents during their
night shifts to unburden them from errant and unnecessary
calls which disturb sleep, and to facilitate their having
some restful periods while on call. We will also continue
to use health extenders such as nurse practitioners, physician
assistants, and hospitalists to form teams to share the
work load. And, we will be pleased to work with any or all
provincial or national working groups to develop fatigue
mitigation strategies and techniques so that our residents
continue to receive the best educational opportunities that
they deserve at the University of Toronto.
Reference:
http://www.ctvnews.ca/health/changes-needed-to-reducefatigue- of-canada-s-medical-residents-report-1.1343905
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