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Chair's Column: Resident Duty Hours - Acknowledging the Unique Aspects of Surgical Training

James Rutka
James Rutka

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.

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.

http://www.ctvnews.ca/health/changes-needed-to-reducefatigue- of-canada-s-medical-residents-report-1.1343905

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