Resident Duty-Hour Cuts Said to Impair Surgical Education, Safety

Some docs say limiting the hours of surgeons-in-training puts patients at risk.

ByCrystal Phend<br><a Href=""target="external">medpage Today</a> Staff Writer
November 06, 2009, 3:56 PM

Nov. 8, 2009&#151; -- Limiting surgical residents' work hours has compromised both surgical education and patient safety, according to an analysis concluding that an 80-hour work week isn't enough.

The maximum 80-work week imposed in the U.S. for residents is too little to provide mastery in surgery, Dr. Gretchen Purcell Jackson and Dr. John L. Tarpley, both of Vanderbilt Children's Hospital in Nashville, Tenn., wrote in online in the British Medical Journal.

Although the cap on working hours was designed to enhance patient safety by keeping exhausted residents away from operating tables and other aspects of patient care, rates of surgical complications and reinterventions actually climbed after the rules were imposed, they said.

Jackson and Tarpley recommended more flexibility in duty-hour limits for surgical residents in particular.

"Surgical disciplines are unique in that surgeons must not only acquire medical knowledge but also develop the manual dexterity and, sometimes, the strength and endurance to perform procedures," they said. "There probably isn't a shortcut for learning surgery."

The 80-hour week limitation in the United States regulations, instituted in 2003 across medical disciplines, is already much longer than 48-hour limit imposed by the European Working Time Directive for trainees in 2009 and the 37-hour week instituted by Denmark.

But even the 80-hour U.S. limit -- twice as long as the standard work week in most industries -- has been met by opposition from groups including the American College of Surgeons who say it's not tough enough.

The adverse effects on healthcare are already serious, but are likely to worsen, according to an accompanying editorial by Dr. Roy Pounder of the University of London.

"We know that many countries are not complying" with the European directive, he wrote, citing Greek and Irish court cases, instances of moonlighting, and "allegedly fraudulent work returns" in other areas.

Hour restrictions have made residents happier in the short term but shortchanged their future in medicine, Jackson and Tarpley argued.

They argued that research suggests that the absolute number of hours, and how they are spent, do matter in turning out competent surgeons.

Five years of clinical training with 50 weeks per year of 80-hour work weeks would provide 20,000 hours of experience over the course of training, which would likely be enough to provide mastery, Jackson and Tarpley said.

However, operative logs from U.S. surgeons who graduated before the duty-hour rules were put in place suggested that operating constituted only about 20 percent of their working time.

Thus, the absolute hours may be less of a challenge for surgical education than getting "the necessary clinical experiences," they said.

"Trainees must also learn to decide who needs an operation, study the relevant anatomy and variations in operative technique, and become skilled at routine and complicated postoperative care," they wrote.

Some recent studies have shown few changes in operative volume and experiences for residents at the end of their training, while less-senior residents have seen a drop of as much as 85 percent in the number of cases in which they act as first assistant.

Residents also appear to have dropped technically advanced cases while picking up more basic procedures to keep up their case numbers, the researchers said.

But Jackson and Tarpley noted that it's still unclear whether these changes have affected clinical competence at the completion of training.

For patients, though, there have been some alarming trends seen, they said.

One study documented an increase in hip surgery complications at teaching hospitals after resident duty-hour reforms, compared with other hospitals.

Another showed a doubling in missed injuries and significant increases in preventable and nonpreventable complication rates at one level I trauma center after the 80-hour work week for residents was adopted.

Residents need to work schedules that allow them continuity of care, so they can "learn the signs of complications and experience the consequences of their decisions" rather than just get brief glimpses into the clinical course of a patient, Jackson and Tarpley said.

If residents can't get enough hands-on patient care and operative experience in the shorter work week, surgical training should be extended, they recommended.

Pounder agreed that flexibility was needed, but not in the blanket, "one-size-fits-all-disciplines" number of hours worked.

"Medical training is no longer a matter of serving time but of acquiring skills and will inevitably vary in length depending on the discipline and the balance of full- and part time work during an individual's career," Pounder said.

He recommended considering training and service aspects and emergency and elective work separately.

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