Whats So Special about an 80-Hour Work Week?

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  • INVITED COMMENTARY

    Whats So Special about an 80-HourW

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    perpoforthacomtice. 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.

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    educational experience must now be by design rather than byaccident, and that requires very careful and thoughtful plan-

    44I do not agree that the work-until-you-drop method wasropriate. The more important questions to ask are as fol-s: What are the residents doing when they are on duty, whatl the general surgeon in 10 years be expected to do, and howwe structure their training program so at the end they arepetent practitioners of our craft? There is nothing magicut 80 hours, and in fact, the appropriate time could be evens, as is anticipated for training in the Netherlands in the

    ning. The fundamental questions raised have not been an-swered because they are not easily resolved. Solutions requirenew thought that is distanced from traditional thinking. Andwe have to take a practical view. Lets first decide what thegeneral surgeon should be and then design the curriculum.Whether it is competency based, an apprenticeship or someother hybrid may vary from institution to institution. Thebottom line is that this has nothing to do with the clock.ork Week?

    hard M. Bell, MD

    partment of Surgery, School of Medicine, Universitylumbia, South Carolina

    Virgilio and his colleagues from Harbor-UCLA Medicalnter offer evidence that the impact of current duty hourtrictions is overall positive. Operative cases increased, ABSITEres were unchanged, morbidity and mortality remained level,the addition of physician extenders to handle the manpower

    uction was accomplished at a nominal cost. The patients re-wed were trauma admissions and cases. I wonder if the sameults would remain true if elective surgical cases were exam-d. This manuscript, however, raises basic questions regard-surgical training that cannot be addressed by a time clock.

    Historically, surgical trainees were on-call every other nightaddition to routine daytime duties. In the final year as Chiefsident, they were on-call every night for their service. Over aear period, residents could reasonably expect to gain suffi-nt experience to finish most programs with the skills to enterependent surgical practice. I describe this as training byident rather than design. Many of my generation oftenport this method by clich: It didnt kill us and look howll we turned out.I am not so sure we know howwell we turned out. The publicception of our profession, not just our specialty, is at a lowint. The ACGME now requires that we develop curriculumour residents to teach them the personality traits and skillst we have taken as a given for many years: interpersonal andmunication skills, professionalism, and systems-based prac-CURRENT SURGERY 2006 by the Association of Program DirectPublished by Elsevier Inc.

    0ialty Clinics, University of South Carolina,

    ure. How do we ensure that the time spent on duty is ofcational value and not consumed by purely service activi-s? This has nothing to do with the time clock, and I submitt 80 hours spent doing busy work accomplishes littleining.These questions are tough. In discussions with my colleaguesoss the United States, I have not found anyone who canvide a confident answer to what a general surgeon will looke in 10 years. Certainly if this creature is expected to care forskin and its content, I seriously doubt that we will be ableproduce such a surgeon in the traditional 5 years of clinicalining. If training is then extended to 6, 7, or even more yearspostgraduate training, how attractive will surgery be to newdical school graduates?I know these issues are being debated by those who establishstandards and requirements, but I am not hearing much inway of answers or guidance. As a program director as well asartment chairman, I question the practicality of some of ouruirements for experience for our general surgery residents inrosurgery, transplantation, urology, orthopedics, and anes-sia. I do not argue the value of these experiences in roundingsurgical trainee, but I wonder if I have the luxury with onlyears and 80 hours a week to produce the traditional generalgeon.We cannot waste 1 minute of the duty hours we have. Theors in Surgery 0149-7944/06/$30.00doi:10.1016/j.cursur.2006.05.007

    Whats So Special about an 80-Hour Work Week?