“what’s so special about an 80-hour work week?”

1
INVITED COMMENTARY “What’s So Special about an 80-Hour Work Week?” Richard M. Bell, MD Department of Surgery, School of Medicine, University Specialty Clinics, University of South Carolina, Columbia, South Carolina de Virgilio and his colleagues from Harbor-UCLA Medical Center offer evidence that the impact of current duty hour restrictions is overall positive. Operative cases increased, ABSITE scores were unchanged, morbidity and mortality remained level, and the addition of physician extenders to handle the manpower reduction was accomplished at a nominal cost. The patients re- viewed were trauma admissions and cases. I wonder if the same results would remain true if elective surgical cases were exam- ined. This manuscript, however, raises basic questions regard- ing surgical training that cannot be addressed by a time clock. Historically, surgical trainees were on-call every other night in addition to routine daytime duties. In the final year as Chief Resident, they were on-call every night for their service. Over a 5-year period, residents could reasonably expect to gain suffi- cient experience to finish most programs with the skills to enter independent surgical practice. I describe this as “training by accident rather than design.” Many of my generation often support this method by cliché: “It didn’t kill us and look how well we turned out.” I am not so sure we know how well we turned out. The public perception of our profession, not just our specialty, is at a low point. The ACGME now requires that we develop curriculum for our residents to teach them the personality traits and skills that we have taken as a given for many years: interpersonal and communication skills, professionalism, and systems-based prac- tice. Fatigue resulting in medical errors is blamed for poor out- comes, and restricting duty hours has been touted as the solution. Not so fast! I am not convinced of the causal relationship. Yet. I do not agree that the “work-until-you-drop” method was appropriate. The more important questions to ask are as fol- lows: What are the residents doing when they are on duty, what will the general surgeon in 10 years be expected to do, and how do we structure their training program so at the end they are competent practitioners of our craft? There is nothing magic about 80 hours, and in fact, the appropriate time could be even less, as is anticipated for training in the Netherlands in the future. How do we ensure that the time spent on duty is of educational value and not consumed by purely service activi- ties? This has nothing to do with the time clock, and I submit that 80 hours spent doing busy work accomplishes little training. These questions are tough. In discussions with my colleagues across the United States, I have not found anyone who can provide a confident answer to what a general surgeon will look like in 10 years. Certainly if this creature is expected to care for the “skin and its content,” I seriously doubt that we will be able to produce such a surgeon in the traditional 5 years of clinical training. If training is then extended to 6, 7, or even more years of postgraduate training, how attractive will surgery be to new medical school graduates? I know these issues are being debated by those who establish the standards and requirements, but I am not hearing much in the way of answers or guidance. As a program director as well as department chairman, I question the practicality of some of our requirements for experience for our general surgery residents in neurosurgery, transplantation, urology, orthopedics, and anes- thesia. I do not argue the value of these experiences in rounding the surgical trainee, but I wonder if I have the luxury with only 5 years and 80 hours a week to produce the traditional general surgeon. We cannot waste 1 minute of the duty hours we have. The educational experience must now be by design rather than by accident, and that requires very careful and thoughtful plan- ning. The fundamental questions raised have not been an- swered because they are not easily resolved. Solutions require new thought that is distanced from traditional thinking. And we have to take a practical view. Let’s first decide what the general surgeon should be and then design the curriculum. Whether it is competency based, an apprenticeship or some other hybrid may vary from institution to institution. The bottom line is that this has nothing to do with the clock. CURRENT SURGERY • © 2006 by the Association of Program Directors in Surgery 0149-7944/06/$30.00 Published by Elsevier Inc. doi:10.1016/j.cursur.2006.05.007 440

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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.

40

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