Surgery requests exemption from new PAIRO guidelines ... or Malcolm Gladwell versus the European Union

Richard Reznick

A TENSION IN OUR MIDST

There is a tension in our midst. This tension is by no means new and indeed has been brewing for decades. It revolves around the issue of attempting to strike a balance between the need for intense exposure and repetitive practice in the development of expertise versus the strong push towards a more balanced lifestyle for our surgical trainees. In Outliers (1), his best-selling book about men and women who do things exceptionally well, Malcolm Gladwell argues that outliers are the product of an intense amount of work in a focused area. He also argues that when they become outliers it is not just because of their own efforts. It's because of the contributions of lots of different people and lots of different circumstances- and that means that we, as a society, have more control about who succeeds-and how many of us succeed-than we think.

Contrast this notion with the inexorable move towards a shortened work week for our surgical trainees. In Europe, this has culminated in a dictate that trainees spend no more than 48 hours in the work place. To put this in perspective, when I trained in surgery, call was onein- two or one-in-three and the average surgical workweek was often 100 hours per week. At present, the work week in the United States is "legislated" at 80 hours, and in Canada, we are roughly at 72 hours per week.

The New PAIRO Guidelines

In the most recent PAIRO-CAHO negotiations the recommended time for departure from the hospital after a night on call for a 24-hour period, is 2 hours after the cessation of the call period. This is in contrast to the current status quo of departure from the hospital by noon after a night on call. The contract provides an opportunity for a service to apply for an exemption from the new regulations. After consultation with our residents and with our senior leadership, the Department of Surgery is seeking such an exemption for all of its services in our teaching hospitals across our eleven residency programs. We are doing so on educational grounds. We are scheduled to meet with PAIRO and a facilitator early in September.

WHY ARE WE SO CONCERNED?

To be sure, we are mindful that the "old way" of 100 hours or more work per week is inappropriate. It does not promote a healthy work-life balance. One could argue that this degree of over-work has resulted in too much marital disharmony, substance abuse and depression. To be sure, the past could be characterized as the misuse of residents as low-cost service providers.

Many would argue that the pendulum has swung too far, as I opined in a Spotlight column five years ago, "Europe has gone crazy". Perhaps the most telling data come from a recent survey done by Richard Bell and colleagues at the American Board of Surgery (2). The Board surveyed program directors in the U.S. and asked them to categorize a list of operations with respect to the expected competency of graduating general surgical specialists. The categories were "must know", "be good to know", and "need not know". It was only in 18 of the 121 "must know" procedures that graduating residents had done more than an average of ten cases. For 83 of 121 the average case load was less than 5, and for 31 of 121 procedures, the average experience was less than one. Indeed, for 63 of these 121 "must know" operations the modal value - the most frequently reported number - was zero.

What makes these data more concerning is that for years we have believed that we need to teach surgical principles and that novice surgeons will rely on these principles when faced with unfamiliar situations. That implies that we believe in the phenomenon of psychological transfer - defined as the process of using knowledge or skills acquired in one context in a new or varied context. This has long been the topic of spirited debate in the psychology research community. One of the leading scholars on transfer, Douglas Detterman, has proffered that educators must assume that transfer is as rare as volcanic eruptions and should operate as though it is virtually unachievable as an instructional goal (3). In reality, many have argued that expertise is a matter of "being there" over and over again. And "there" is the very narrow arena in which one has had ample deliberate and focused practice.

THE ANSWER TO OUR TENSION

It is clear to me that we are on a pathway towards collision. Training is already too long and if we head towards a European work week of 48 hours, we will undoubtedly train surgeons with less skill and knowledge than their teachers. I strongly believe that what is needed is a new way of thinking about surgical training coupled with new training models. On July 1, 2009 we inaugurated a new stream in Orthopaedic Surgery, under the guidance of Ben Alman, Bill Kraemer and Peter Ferguson. This new stream has three residents who will learn orthopaedic surgery in a modular competency-based fashion. This proof of principle experiment will offer very different training from the conventional curriculum. The Royal College has agreed that residents in this new stream will be able to sit their fellowship examinations when the faculty believe they are competent, which may be in the traditional five years of training, but may be less. The Ministry of Health and Long Term Care, interested in supporting innovation and new approaches to health human resource issues, have granted us $1.7 million dollars to roll out this program over the next four years.

To be sure, we can no longer tinker at the edges of surgical curricula. The imperative of patient safety, the reality of the cost of the surgical minute, the need to abandon the 100+ hour work week of the past are all in conflict with the mission of producing highly capable surgeons. In conflict, unless we challenge our current methods and develop and implement new models of training.

Richard K. Reznick
R. S. McLaughlin Professor and Chair

(1) Gladwell M. Outliers. New York, NY: Little, Brown and Company,. 2008. http://www.gladwell.com/outliers/index.html

(2) Bell RH et al. Operative Experience of Residents in US General Surgery Programs. Annals of Surgery: 249:719- 724: 2009

(3) Detterman DK, Sternberg R. Transfer on Trial: Intelligence, Cognition and Instruction New York, NY: Ablex Publishing, 1993.

For more on Malcolm Gladwell's essay on "10,000 hours to expertise", see editors column.