How work-hour restrictions harms resident surgeon training

Controversy persists about limiting the work hours of resident physicians.

No where is it more prevalent than in surgery, where proficiency depends on the number of times a trainee physician performs a procedure. In a recent study from the Journal of the American College of Surgeons, 43 percent of surgical residents want to work more than the allotted 80 hours per week, and 41 percent felt the work-hour restrictions “were a ‘considerable or moderate barrier’ to their training.”

I’ve mentioned previously that there is little definitive data that suggests that capping resident work-hours leads to an improvement in patient care, but there is growing evidence that tired doctors make more medical errors.

With talk of capping work-hours further, I think it’s inevitable that another year will eventually be added to resident training programs. As it stands, there’s a danger that the next generation of physicians will be ill-prepared to practice medicine without a net.

Comments are moderated before they are published. Please read the comment policy.

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    I think there are some issues that do not require ‘data’ to make sound decisions. Personally, I don’t need a scientific study to convince me that airline pilots perform better when they are sober. I don’t need a peer reviewed report to convince me that young kids shouldn’t play in traffic. Similarly, do we still need data that exhausted interns and residents shouldn’t be caring for sick patients? Those that continue to support the policy of having stuporous housestaff managing complex in-patients often have an agenda unrelated to patient care or medical training. Who would these folks want caring for them or their families? A resident who is rested or one who is somnambulating?

  • http://askanmd.blogspot.com/ Doctor D

    Surgery is still a macho culture. I have heard surgeons have penis measuring contests arguing who could spend the most consecutive hours in an OR. “I can operate 36 hours straight. All I need is some coffee!”

    I’m not sure a poll of surgery residents claiming they would like to work more than 80 hours should be trusted. When group of professionals try to act like supermen it is the job of professional standards to set some limits for those who cannot recognize their own limit. We don’t want patients hurt when a surgical resident tries to show how tough he is by operating without sleep.

  • http://thehappyhospitalist.blogspot.com/2009/07/storms-on-horizon.html Happy Hospitalist

    There are no shortcuts to education

  • Chris P

    If the surgeons were such supermen, perhaps they would be able to discover ways of working within the structure of the hours limits to get their training in. This survey might say a lot about the problem solving capacity of the surgical community.

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    Nor should there be shortcuts to patient care.

  • annieRN

    As an OR nurse, I have at times discretely jabbed an exhausted resident or student in the ribs when I see their eyes closed. I seriously doubt that they are learning anything during those “down” times, let alone contributing to any team effort. I know they’re terribly embarrassed when I do this, but I’m sure some would have actually keeled over if I didn’t.

  • DocbLawg

    Would imposing the 80 hour week have saved Libby Zion? The case of Libby Zion is the one that set the standard for the 80 hour work week for residents. While personally I would not want to see a doctor who is spent and functioning on a caffeine high, I would also want to see a doctor who is skilled and knowledgeable having gone through the rigorous training necessary to become specialized. If it takes adding a year or two to a training program in order to train future specialists to the extent of their predecessors so be it.

  • http://www.ohiosurgery.blogspot.com buckeye surgeon

    I’m the surgeon I am today because of my training (100-120 hrs/week as a junior resident). The surgeons of tomorrow are going to be what you get when you expose them to 70-80% of the workload. That’s just the way it is. How surgical practice is structured will certainly have to change. But let’s not get carried away with depictions of sleep walking zombies roaming our OR suites at 3am. You have to perform. Your patients depend on you. Not every one is cut out for such a grueling schedule. Just wait until these newer residents have a weekend where they have to stay up TWO WHOLE nights in a row doing appies/free air/trauma cases! They might get sleepy even! I wrote about such a marathon here (http://ohiosurgery.blogspot.com/2008/07/are-you-guys-ready-for-this.html). But whatever. Work hour reform is inevitable.

  • T Steadmon

    Having graduated medical school in the last five years, I feel that true training begins too late in medical education. My fourth year of med school consisted of required rotations that required me to stay at the hospital until around noon five days a week. I would work with different specialists and when they found out I was going into a residency outside of their specialty, they had no interest in teaching.

    Also, several of my colleagues that did surgery hardly scrubbed in to any cases until their second year of residency. They were doing over 80hrs per week of scut work in the ICU and surgical floor and never made it into the OR. Many of them didn’t meaningfully participate in the operations until their THIRD year of residency.

    The probelm is not that 9 years is not long enough time for training. I think a lot of the problem is wasting a lot of the 9 years on activities that provide limited benefit.

  • Anon

    From the article:

    “More than a third of surgical residents think that regulations designed to limit their work schedules to a maximum of 80 hours per week represent a “significant barrier” to their training.”

    That’s true. Equally true is that two-thirds don’t. A more appropriate headline would be:

    “Majority of surgical residents favor work hour restrictions”

    What an interesting way to present statistics – highlighting the minority view and making it sound like the majority.

  • Frank Drackman

    Surgeons are the Alpha-Dogs of Medicine…
    I’m yawning by the time we roll the first case into the OR…what is that 7:31am???
    3:30 can’t get here fast enough…
    Thats the great thing about Anesthesia residency, you miss 90% of the good On-call Cases…and 100% of the Post-Call ones…

    Frank

  • guy

    to all of the people who say that we should make the hours that people are at work more effective, how exactly would you do that, there are a finite number of cases, you either get more residents to cover nights and weekends but they get less overall cases so they have to work more or you have folks that are out do the cases that residents can’t do because of work hour restrictions. We know that people who do more cases do better at those cases, practice does make perfect.

  • KirschMD

    Give me a break. 43% of residents actually WANT to work over 80 hours a week? Something tells me that their chairmen were getting copies of these surveys. I came up through surgical residency before the restrictions and I gained nothing from SCUTTING into the wee hours except for contempt for the profession.

    At least half of the work, particularly at the junior level, can and should be done by ancillary staff. Unfortunately, residents are looked at as a cheap source of 24 hour labor by addendings and hospital adminstrators who perversely label slavery as education.

  • Erik

    It’s funny how when it was my father that had peritonitis, I didn’t think waiting until the surgeon finished his nap was acceptible. When my aunt had her MI, I wasn’t willing to let the cardiologist wait a few hours before the emergent cath either.

    Either stop calling it medicine and rename it doctoring (which occurs with regulated hours) or accept that people sometimes get sick at incovient times, and that tired docs will do the best they can. I’m really glad that the (superb) docs who treated my family members had done enough procedures while they were exhausted that they could do the techinically demanding work (making it look effortless).

    I didn’t much enjoy my MICU rotations as a resident with the 24 hour call but I did learn how to stablize someone quickly in the middle of the night. It is not responsible to graduate residents in any field who have not mastered the basic skills of their field.

    Even pathologists take call!

  • T Steadmon

    In response to guy:
    1) eliminate the 4th year of medical school. nothing of value is learned during this year. mine consisted of a few weeks each of several different fields of medicine, but it was on par with shadowing as a premed student (though at least as a premed shadow the doctors taught and I felt I was learning something)

    2) at least for surgery residency, don’t accredit institutions to accept residents unless they have the ancillary staff available to run a hospital. too many hospitals with residents are underfunded and literally depend on residents doing hours of scut work that contribute nothing to their education. as i said in my previous post, many surgery residents do not meaningfully participate in surgery until their 3rd year of residency because they are camped out in the MICU and surgical floors for over 80hrs a week. this means 40% of their residency has evaporated by the time they get to really learn to operate. even if they don’t get to operate until 2nd or 3rd year, if they weren’t working >80hrs per week they might have a chance to actually read a textbook to learn some things about surgery. my surgery colleagues were always so exhausted and stressed they rarely had the energy to spend time reading. in other residencies it is common for residents to read 3hrs assigned reading per night after work with lectures the next day on the material. some institutions spread residents so thin, the scut work done by the residnets becomes critical to the functioning of the hospital at the expense of their education.

  • greg zurbay

    Being sleep deprived equals being under the influence, according to recent research. With this information a consistent person would conclude we should also agree with the wisdom of permitting the drunk driver unfettered use of motor vehicles. Go ahead, convince me otherwise.

  • http://thehappyhospitalist.blogspot.com Happy Hospitalist

    teenage drivers also have one of the highest rates of accidents. And they are the least experienced.

Most Popular