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Page 1: “What’s So Special about an 80-Hour Work Week?”

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NVITED COMMENTARY

What’s So Special about an 80-Hourork Week?”

ichard M. Bell, MD

epartment of Surgery, School of Medicine, University Specialty Clinics, University of South Carolina,

olumbia, South Carolina

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e Virgilio and his colleagues from Harbor-UCLA Medicalenter offer evidence that the impact of current duty hour

estrictions is overall positive. Operative cases increased, ABSITEcores were unchanged, morbidity and mortality remained level,nd the addition of physician extenders to handle the manpowereduction was accomplished at a nominal cost. The patients re-iewed were trauma admissions and cases. I wonder if the sameesults would remain true if elective surgical cases were exam-ned. This manuscript, however, raises basic questions regard-ng surgical training that cannot be addressed by a time clock.

Historically, surgical trainees were on-call every other nightn addition to routine daytime duties. In the final year as Chiefesident, they were on-call every night for their service. Over a-year period, residents could reasonably expect to gain suffi-ient experience to finish most programs with the skills to enterndependent surgical practice. I describe this as “training byccident rather than design.” Many of my generation oftenupport this method by cliché: “It didn’t kill us and look howell we turned out.”I am not so sure we know how well we turned out. The public

erception of our profession, not just our specialty, is at a lowoint. The ACGME now requires that we develop curriculumor our residents to teach them the personality traits and skillshat we have taken as a given for many years: interpersonal andommunication skills, professionalism, and systems-based prac-ice. Fatigue resulting in medical errors is blamed for poor out-omes, and restricting duty hours has been touted as the solution.ot so fast! I am not convinced of the causal relationship. Yet.I do not agree that the “work-until-you-drop” method was

ppropriate. The more important questions to ask are as fol-ows: What are the residents doing when they are on duty, whatill the general surgeon in 10 years be expected to do, and howo we structure their training program so at the end they areompetent practitioners of our craft? There is nothing magicbout 80 hours, and in fact, the appropriate time could be even

ess, as is anticipated for training in the Netherlands in the b

CURRENT SURGERY • © 2006 by the Association of Program DirPublished by Elsevier Inc.

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uture. How do we ensure that the time spent on duty is ofducational value and not consumed by purely service activi-ies? This has nothing to do with the time clock, and I submithat 80 hours spent doing busy work accomplishes littleraining.

These questions are tough. In discussions with my colleaguescross the United States, I have not found anyone who canrovide a confident answer to what a general surgeon will look

ike in 10 years. Certainly if this creature is expected to care forhe “skin and its content,” I seriously doubt that we will be ableo produce such a surgeon in the traditional 5 years of clinicalraining. If training is then extended to 6, 7, or even more yearsf postgraduate training, how attractive will surgery be to newedical school graduates?I know these issues are being debated by those who establish

he standards and requirements, but I am not hearing much inhe way of answers or guidance. As a program director as well asepartment chairman, I question the practicality of some of ourequirements for experience for our general surgery residents ineurosurgery, transplantation, urology, orthopedics, and anes-hesia. I do not argue the value of these experiences in roundinghe surgical trainee, but I wonder if I have the luxury with onlyyears and 80 hours a week to produce the traditional general

urgeon.We cannot waste 1 minute of the duty hours we have. The

ducational experience must now be by design rather than byccident, and that requires very careful and thoughtful plan-ing. The fundamental questions raised have not been an-wered because they are not easily resolved. Solutions requireew thought that is distanced from traditional thinking. Ande have to take a practical view. Let’s first decide what theeneral surgeon should be and then design the curriculum.

hether it is competency based, an apprenticeship or somether hybrid may vary from institution to institution. The

ottom line is that this has nothing to do with the clock.

ectors in Surgery 0149-7944/06/$30.00doi:10.1016/j.cursur.2006.05.007

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