The FIRST (Flexibility in Duty Hour Requirements for Surgical Trainees) trial randomized American surgical residency programs to one of two arms:
- Standard group continued with their current standard restricted hours practice of 80 hours per week with time for breaks/rest and a limit to hours of work at any one time.
- “Flexible” hours group removed current restrictions on hours worked at any one time and waived the need for breaks etc., whilst somehow maintaining the same overall 80 hour per week average.
Data was collected via systems and surveys that are already undertaken in the USA to establish if there was any detriment to the patient or the surgeon.
It has often been considered by those outside and inside the profession that surgeons are not human — and now we have it confirmed, as this trial, which included an intervention that impacted human subjects — was somehow classified as “non-human subjects” research, thus not subjecting it to a more in-depth review.
How did it get classified as non-human subjects research?
A look at the supplementary information shows the box was ticked that claimed it was limited to the use of existing or collected data. However, it was not in fact solely limited to that. An intervention was applied — an intervention which, whilst it was applied to residency programs, impacted and affected the lives of human subjects. Calling the intervention a “policy change” that randomized residency programs (not individuals) does not take away from the fact that this research involved an intervention that affected living human subjects. Has the correct box been ticked? Has there been fudging of information so as what is in fact human subjects’ research is somehow classified as not?
All very convenient when you have a specific aim and agenda to fulfill with the backing of the American College of Surgeons, the American Board of Surgery and the Accreditation for Graduate Medical Education — I imagine any IRB (institutional review board) would have difficulty contravening the weight of those establishments!
In addition, how is it possible to maintain 80-hour week average for both groups and yet have one group waive all restrictions on their work hours?
Sounds like magic to me — squeezing time itself! There is no mention of how the study arm group limited their overall hours to 80 per week. And what is even more concerning is the statement that “monitoring to ensure strict adherence to study arm conditions was not undertaken” or in other words, “we have no idea if the total hours worked in the study arm exceeded 80 or not and we don’t care if it did.”
Furthermore, using gross measures of outcome like patient mortality is not an accurate marker as teams of nurses and doctors — not just one trainee — care for patients. More sensitive measures of outcome were not utilised.
It does report that there were some differences in well-being, with those in the “flexible” hours group reporting negative effects on activities away from the hospital like time with friends and family, extra-curricular activities, research time and rest/health — again suggesting that the 80 hours limit was exceeded or else they would have had the same amount of time outside work.
Also, the resident survey was conducted half way through the trial, not at the end of the trial, when a bigger discrepancy may have been noted. Given there were differences at six months, what would they be at one year? At 2, 5, 10 years, at 20 or 30 years?
If there are no detrimental effects to long hours of work then why are burnout rates amongst surgeons in the USA around 50 percent?
This perception of not being human plays out in many ways. We arrogantly believe we can work extremely long hours yet not get affected or have our work or our own health detrimentally affected. I used to be of that view too. Proponents of this trial will say that this is the case and that it has been confirmed or validated by trial, opening the door to abusively long hours of work once more. Yet other humans like airline pilots and lorry drivers are restricted in their hours of work because it has been shown that human error increases with fatigue. So is the answer that surgeons are indeed not human and not subject to the same laws of life as everyone else or is something else going on?
As trainee surgeons we are pretty resilient, we want to work hard and do well for our patients, often to the detriment of our own health and well-being, and are used to overriding our bodily needs, often priding ourselves on our levels of stamina, endurance and ability to go not just the extra mile, but perhaps the extra marathon.
We love what we do and we are happy to spend long hours in theater or at work, to provide good quality care and to get the experience needed to be a competent surgeon. I get it. I’ve been there, done it, got the tee shirt.
I know what it is like to work continuous hours of duty for weeks at a time with night after night of sleep deprivation culminating in a cotton wool head, hardly able to string two words together. I recall handing over to my colleagues when I was going off for 48 hours and hearing them fall asleep on the end of the line as they continued on duty. One even recounted how he fell asleep whilst assisting, standing up! And we think all of this has no effect on our performance or well-being? Come on!
If there are no detrimental effects to long hours of work then why are burn out rates amongst surgeons in the USA around 50 percent?
It’s not rocket science! Yes, multiple factors contribute to that, but we have basic human needs that, if we override for long enough, will come back to bite us in the bum.
Research shows that sleep deprivation is associated with a multitude of conditions like heart disease, diabetes, dementia and more. Our lifestyle is a major determinant of our health and well-being — and whilst we may not believe or notice these effects when we are young, they undoubtedly take their toll on the human body over time.
I also know the frustrations that can come from there being a lack of continuity of care by junior staff. I understand the surgical mindset that laments the days of yore — but those days, at least in the UK, are gone. It is not about returning to those days, but how do we improve our systems, structures and personal levels of well-being such that quality of patient care is maintained? Knowing how to work hard and remain healthy is currently not part of mainstream knowledge or surgical training but it needs to be.
And so whilst I fully appreciate the need for both high-quality care and surgical training, I also am acutely aware of the need to not abuse trainees in the process or to have them exploited by programs and people who do not care for the well-being of the trainee and assume that just because they did it, everyone should do it.
If we do not care for ourselves, we cannot provide a true quality of care to others — for we cannot give what we do not have. A trainee who is self-caring, alert, vital, vibrant, aware and fully present undoubtedly delivers a quality of care that is superior to one who is tired, exhausted, sleep deprived, overdosing on caffeine and who overrides their own bodily needs. The environment within which we work can be supportive and engendering of such qualities or it can be highly abusive, and detrimental to the trainees’ own well-being — and trainees in pursuit of their dream job are all too often only too willing to subjugate their own needs for professional progress.
So just for the record — surgeons are human, not superhuman, we have the same bodies made of the same stuff as everyone else, we get just as tired and detrimentally affected by persistently long hours of work devoid of self-care as other professions, we are perhaps just better at denying, ignoring and overriding the fact that we do.
Unfortunately, this trial belongs to the waste paper bin for it is nothing more than a biased, pre-determined, agenda-laden study, undertaken on false pretenses of being a non-human subject study designed to permit the ongoing abuse and exploitation of trainee surgeons — who themselves are often so enwrapped in their desire to pursue a surgical career that they do not even recognize when they are being abused or when they are abusing their own bodies.
Having been there myself — I know it only too well.
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