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56 Hour resident work hour restrictions

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SocialistMD

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Not sure where this came from. The fact that you cannot debate the shortening of work hours to those outside of the surgical profession, and I argue you are no different than any other medical professional, is bothersome.

The notion that "I am a surgeon and you cannot possibly understand" is not a position a moderator on this forum should be taking.
Let it go. The point being made is you, a non-surgeon, do not know what is important for our training, so to say it is wrong and should be abandoned for something you feel is better is pointless. Do you think Navy SEALs should not endure "hell week" in their training, or do you think the ends justify the means? You are hearing from people who are currently or were recently in the surgery residency trenches who are telling you we feel having the experience of operating somewhat fatigued is (a) not as dangerous as you (and other people who have never done it) think it is and (b) is important because we know we will face that situation at some point in our career and want to have that experience in less stressful environments with more senior backup.
 

ANCAdoc

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Some of your surgical colleagues have shown reduced complications and mortality post-resident work hour restrictions. Yes, it is retrospective and observational, but I know of no randomized prospective studies.

As recent as 2008 the ACS prepared a position statement and sent it to the IOM. One of their main pillars was the lack of evidence for improved patient safety s/p work hour restrictions. Well, evidence is slowly coming out. Of course it will start with retrospective studies, but over time will hopefully include randomized studies.



"Implementation of resident work hour restrictions is associated with a reduction in mortality and provider-related complications on the surgical service: a concurrent analysis of 14,610 patients."

Ann Surg. 2009 Aug;250(2):316-21

CONCLUSIONS: Implementation of RWHR was associated with reduced provider-related complications and mortality suggesting improved patient safety. This was likely due to several factors including reduced resident fatigue and greater attending involvement in clinical care.
 

Tigerz_Fan

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Clarification: not just surgeons but every practicing medical professional (in the context of working 30hrs)

Seriously, enough already. I will not pretend to know or even comprehend what surgeons must endure to do their job, and take care of patients.
 
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ANCAdoc

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Another retrospective study showing decreased mortality s/p work hour restrictions in a surgical population as well as a retrospective study showing no decrease in #cases performed nor board scores in an ortho population s/p work hour restrictions. Again, all retrospective, but hopefully provides enough impetus to fund prospective studies.

I only throw these out since I was scorned by WS and others in surgery that I simply don't understand.


The Impact of Resident Work-Hour Restrictions on Outcomes of Cardiac Operations.

J Surg Res. 2009 May 3. [Epub ahead of print] - Baylor COM study (TX)

CONCLUSIONS: Cardiac operations performed after the resident work-hour restriction went into effect were associated with significantly lower adjusted 30-d and 6-mo mortality rates than were operations performed before the work-hour restriction became effective.


Impact of the 80-hour workweek on surgical exposure and national in-training examination scores in an orthopedic residency program.

J Surg Educ. 2009 Mar-Apr;66(2):85-8

CONCLUSIONS: We found no statistical difference for each residency class in the average number of cases performed or OITE scores.
 

NotAProgDirector

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A great discussion. I have the utmost respect for both sides.

1. Each side has it's own concerns, and feels that their concerns are dominant to the other's. This is very similar to other contentious debates -- liberal vs conservative, abortion vs prolife, "tastes great" vs "less filling". The point is that, from the trenches it can be hard to see the other's viewpoint has merit.

2. There is clear evidence that sleep deprivation increases errors. This has been tested in multiple venues and is pretty well established. It has not been proven for surgery clearly. Two studies recently (here and here) looked at simulator functioning post call. These were simulator based, and hence it's possible that the functional deficits seen in the simulator are statistically significant but not clinically significant. Older studies have looked at laproscpic trainers with similar results. In fact, the only study I could find looking at clinical outcomes demonstrated no difference.

3. On the other hand, surgery is somewhat different from other medical fields. If a patient who has been recently operated upon needs a second / repeat / rescue procedure, the surgeon that has recently operated on that patient MIGHT be the best person for the job.

Supporting this theory:
  • This surgeon knows this patient's anatomy best.
  • This surgeon knows exactly what happened in the OR the last time.
  • This surgeon probably has an established relationship with the patient and family.

Opposing this theory:
  • This surgeon might be too tired to perform at their best.
  • This surgeon may have misinterpreted abnormal anatomy the first time. In a second operation, they may do so again. Sometimes a fresh set of eyes is the best medicine
  • This surgeon may be less-than-fully-competent. If so, it will be hard to assess this unless another surgeon evaluates patients with adverse outcomes.

Whether or not the original surgeon is the best person to perform the second operation depends entirely on how you weigh the above factors (and I'm sure there are more that I have missed). For example, there may be other ways to pick up surgeons with skill issues -- surgical M&M, or some sort of standardized outcome assessments, for example.

4. The notion that you can learn to "deal with" sleep deprivation via practice is controversial. Most "sleep experts" feel this is simply not true -- much like people who drink before driving stating that because they do it all the time, they can drive fine while intoxicated. Most studies of this effect (none done in medicine, to my knowledge) do suggest that sleep deprivation causes a deterioration in cognitive functioning, which is physiologic and cannot be mitigated by practice.

5. However, WS does raise an important point. Some people likely need less sleep than others. Perhaps the average person needs 8 hours, but WS really needs 4.5. This raises a really thorny question: Perhaps we should limit surgery training to those who function well on less sleep. As WS points out, this happens somewhat already via "natural selection", but what if someone who needs 8 hours is simply "dying" to be a surgeon? Also, what happens if WS (or anyone else) finds that as they grow older, they can't do well on 4.5 hours. Is someone really watching?

6. The legal liability of sleep deprivation cannot be ignored. The example suggested by IUSM is completely germain to this discussion. Here's the scoop: if anyone (in any field) is up for 24-30 hours and then drives home, and gets in an accident, it is likely that both they and their emplyer will be liable for damages. There are several states that have laws specifically addressing MVA's and drivers with 24+ hours without sleep. More will follow. Even if surgeons are able to function well in the high stress venue of the OR after little sleep, they are almost certain to not do as well when driving a car tired.

7. As WS has mentioned, there is a flip side. Less hours working = less time in the OR. There is no way around that, other than lengthening training which seems impossible unless we change the way training works (i.e. you get a "junior position" after a number of years that pays much better than a resident, or some other similar change). Less experience might cause graduating surgeons to be less skilled. There is no evidence that this is true, but many senior surgeons fear it.

8. There is also a "resource utilization" issue here. Let's say you work in an inner city hospital. There are certain to be 2 major traumas every night. In such a case, it would make sense to have a trauma surgeon on call at night, doing shift work. It would be crazy to have someone be "on call", be certain that they would get no sleep, and then assume that they could work the next day without a problem. It would make more sense to work a week of nights, and have the rest of your schedule be empty. ON the other hand, if you work in a rural hospital where trauma's are uncommon, it would make no sense to have someone "in house, well rested, at the ready" all the time for something that rarely happens. But, when it does happen, you either need a contingency plan for the next day or just "live with it".

... unless there simply aren't enough trauma surgeons to go around. Sure, it would be great to have someone covering the night shifts, and the day shifts, but that assumes you have enough people to do it all, and you're willing to pay the cost.

So, where are we?

A. I do not doubt that more tired surgeons make more mistakes. In fact, there are several recent articles (here and here) that suggest this is true.

B. If we want less tired surgeons (because we think they give better care), then we will need to be willing to pay more for that privilege.

C. If we want less tired surgical trainees, then 1) we need to be aware that this may cause them to have less surgical skills upon graduation which could overwhelm any improvements from a lack of sleep deprivation, or 2) we need to make large changes to the way we train surgeons (by somehow getting them more OR experience while hours are reduced). I see no easy way to do that, unless teaching programs currently have many cases where only faculty scrub in.

D. If we do want to fix this, the problem is not the 80 hour work week. The problem is 24+6 shifts. We could consider limiting shift length, with 16 hours often suggested as the maximum. It might be possible for surgical trainees to work multiple 12-16 hour shifts weekly and still get 80 hours of experience and plenty of cases. Whether this will actually lead to more well rested surgical residents is not clear. If this results in more cases not having residents present (because their shifts are over and there is no way to cover all shifts with the residents available) then it will lead to less OR experience for residents. Note that increasing residency program sizes, although it will help cover shifts, will still dilute the training experience amongst more residents (again, unless there are a significant number of "resident-less" cases already)

Wow, that ended up being much longer than I expected. Looks like an IM admission note, doesn't it? :laugh: I'll stop now.
 

Winged Scapula

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Thank you aPD for clarifying all the issues and getting the heart of the differing opinions. It is much appreciated.

The Impact of Resident Work-Hour Restrictions on Outcomes of Cardiac Operations.

J Surg Res. 2009 May 3. [Epub ahead of print] - Baylor COM study (TX)

CONCLUSIONS: Cardiac operations performed after the resident work-hour restriction went into effect were associated with significantly lower adjusted 30-d and 6-mo mortality rates than were operations performed before the work-hour restriction became effective.

However, they did not control for how much of the procedure was done by the trainee and with attending presence. "Back in the day" senior surgery residents often did cases, even cardiac surgery, without attendings even scrubbed in. Residents could book cases and Chiefs do them without an attending present.

This is rapidly fading and is non-existent in many programs. Now it is not uncommon for Chief Residents to be assisting the attending and/or even the CT PA who is opening and closing. With work hour reductions, attendings HAVE noticed less skills in many residents and are therefore, less inclined to let the resident have autonomy. The increased liability environment also contributes to this tendency.


Impact of the 80-hour workweek on surgical exposure and national in-training examination scores in an orthopedic residency program.

J Surg Educ. 2009 Mar-Apr;66(2):85-8

CONCLUSIONS: We found no statistical difference for each residency class in the average number of cases performed or OITE scores.

Same problem here. I can tell you that before the restrictions residents were told to lie about not having too many cases? Those 1200 cases your Chief residents did? Make it 2000 "back in the day" which was never reported because residents, myself included, were cautioned not to report much more than 1200 because the RRC would worry that we were spending too much time in the OR...and this was BEFORE work hour restrictions. ALL of us actually did more cases than we reported to ABS.

Therefore, using "average number of cases performed" is not an accurate measure. The numbers have always been lied about - whether to reduce the total number or now to stretch the truth and add cases to reach the minimum in each category.

And the fact that resident scores did not go up after work hour restrictions only highlights the fact that residents of all stripes are not using the extra hours to go home and study but rather to spend time with family, at the gym, sleep, etc. Traditionally, the Surgical ITE was not clinically based...so having a great score never did, and still doesn't, translate into someone who is a good surgeon. So using it as some sort of measure that the 80 hour work week is a great idea doesn't make sense.

I am not sure that studies "before and after" are really worthwhile when most of us realize that many surgical programs are not adhering to any work hour restrictions. The glaring examples of being in the hospital for 3 days in a row are less common, but many will express that they are still working over 100 hours per week.

I'm sorry if those involved felt that I was being adversarial; it was not my intent, but as aPD has clearly pointed out, there are issues that I feel that no man can understand until he has walked in those shoes.
 
N

njbmd

Thank you aPD for clarifying all the issues and getting the heart of the differing opinions. It is much appreciated.



However, they did not control for how much of the procedure was done by the trainee and with attending presence. "Back in the day" senior surgery residents often did cases, even cardiac surgery, without attendings even scrubbed in. Residents could book cases and Chiefs do them without an attending present.

This is rapidly fading and is non-existent in many programs. Now it is not uncommon for Chief Residents to be assisting the attending and/or even the CT PA who is opening and closing. With work hour reductions, attendings HAVE noticed less skills in many residents and are therefore, less inclined to let the resident have autonomy. The increased liability environment also contributes to this tendency.




Same problem here. I can tell you that before the restrictions residents were told to lie about not having too many cases? Those 1200 cases your Chief residents did? Make it 2000 "back in the day" which was never reported because residents, myself included, were cautioned not to report much more than 1200 because the RRC would worry that we were spending too much time in the OR...and this was BEFORE work hour restrictions. ALL of us actually did more cases than we reported to ABS.

Therefore, using "average number of cases performed" is not an accurate measure. The numbers have always been lied about - whether to reduce the total number or now to stretch the truth and add cases to reach the minimum in each category.

And the fact that resident scores did not go up after work hour restrictions only highlights the fact that residents of all stripes are not using the extra hours to go home and study but rather to spend time with family, at the gym, sleep, etc. Traditionally, the Surgical ITE was not clinically based...so having a great score never did, and still doesn't, translate into someone who is a good surgeon. So using it as some sort of measure that the 80 hour work week is a great idea doesn't make sense.

I am not sure that studies "before and after" are really worthwhile when most of us realize that many surgical programs are not adhering to any work hour restrictions. The glaring examples of being in the hospital for 3 days in a row are less common, but many will express that they are still working over 100 hours per week.

I'm sorry if those involved felt that I was being adversarial; it was not my intent, but as aPD has clearly pointed out, there are issues that I feel that no man can understand until he has walked in those shoes.

I have to agree with WS with the above. Both of us had some surgical residency years under the old system and trained through the institution of the new work hours restriction. I too had many more cases that I reported to the ABS because of being warned not to have too many cases.

My program did everything possible to adhere to work hour restrictions but in many cases (at our VA for example), this just wasn't possible. We sent people home as much as possible and we tried to average out the time so that we stayed in compliance. Were we 100%? Certainly not, but we were not disregarding hours either but we went over hours at times.

In terms of ABSITE, my best scores were my PGY-1 year when I was under the old system with the longer hours. While I was in the hospital longer, I didn't have the large patient load that I acquired with our night float system. My score percentage dropped a bit every year. My PD didn't care so much as long as I was getting the job done and acquiring sound surgical skills.
 

calvinNhobbes

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Something I learned about during a surgery elective in medical school called 10,000 hour mastery in Malcolm Gladwell's book, Outliers: The Story Of Success.

Basically, it takes 50 hours to become competent at something (shooting free throws, driving, doing an H&P, etc.), but to truly master something so that you are at the best of your ability takes 10000 hours of training. In general, it takes about 10 years to do that if you practice 20 hours a week doing that one thing.

Medical procedures and surgery need to be mastered. That takes alot of time. And the thing about surgery that makes it special is you can't really "practice" surgery like you can sports or other activities. Sure you can pratice knot tying, or scope simulators, or saw bones, but those are inadequate replacements for the real living bleeding tissue. You need 10000 hours of OR time.
 

SocialistMD

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Something I learned about during a surgery elective in medical school called 10,000 hour mastery in Malcolm Gladwell's book, Outliers: The Story Of Success.

Basically, it takes 50 hours to become competent at something (shooting free throws, driving, doing an H&P, etc.), but to truly master something so that you are at the best of your ability takes 10000 hours of training. In general, it takes about 10 years to do that if you practice 20 hours a week doing that one thing.

Medical procedures and surgery need to be mastered. That takes alot of time. And the thing about surgery that makes it special is you can't really "practice" surgery like you can sports or other activities. Sure you can pratice knot tying, or scope simulators, or saw bones, but those are inadequate replacements for the real living bleeding tissue. You need 10000 hours of OR time.

One also needs to master the care of patients outside of the OR (something that can't be done while in the OR). An interesting coincidence:

80hrs/wk * 49 wks/yr (average 3 wk vacation) =3,920 hrs/yr
10,000/3,920 =~2.5 yrs.

And that, ladies and gentlemen, is why surgery is a 5-year program...
 

Impromptu

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We had our mandatory intern year lecture on sleep deprivation recently. One thing I found interesting is that the individual is a poor judge of their own levels of alertness, fatigue, and ability. We overestimate ourselves. This may especially come into play when that AM circadian bump in relative feeling of awakeness kicks in for post-call residents. We feel more awake, but our ability is still decreasing. We are like the beer drinker who doesn't realize how drunk he really is. Perhaps simply realizing that we are not at our best will help us slow down and do things more methodically, to dig deeper into our experience and training rather than our impaired intellect.
 

Winged Scapula

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We had our mandatory intern year lecture on sleep deprivation recently. One thing I found interesting is that the individual is a poor judge of their own levels of alertness, fatigue, and ability. We overestimate ourselves. This may especially come into play when that AM circadian bump in relative feeling of awakeness kicks in for post-call residents. We feel more awake, but our ability is still decreasing. We are like the beer drinker who doesn't realize how drunk he really is. Perhaps simply realizing that we are not at our best will help us slow down and do things more methodically, to dig deeper into our experience and training rather than our impaired intellect.

That is a valid concern for any field.

While we should self-police, we also have to be aware of our colleagues that might not be performing up to snuff...whether due to sleep dep, drugs/ETOH, depression, etc.
 

calvinNhobbes

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One also needs to master the care of patients outside of the OR (something that can't be done while in the OR). An interesting coincidence:

80hrs/wk * 49 wks/yr (average 3 wk vacation) =3,920 hrs/yr
10,000/3,920 =~2.5 yrs.

And that, ladies and gentlemen, is why surgery is a 5-year program...

Wow, that is interesting. I think the concern most surgical residents have is that OR time is the first thing that will be reduced if further hour restrictions are implemented, not patient care. However, both are obviously critical.
 

SocialistMD

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Wow, that is interesting. I think the concern most surgical residents have is that OR time is the first thing that will be reduced if further hour restrictions are implemented, not patient care. However, both are obviously critical.

If anything, it can be cited as support for the fact that surgical training is at its breaking point at 80hours and to reduce that further will lead to inadequately trained surgeons (unless you lengthen training, which I'm not in favor of, seeing how it is already going to take me 10 years to finish residency/fellowship).
 

Stealth Vector

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If anything, it can be cited as support for the fact that surgical training is at its breaking point at 80hours and to reduce that further will lead to inadequately trained surgeons (unless you lengthen training, which I'm not in favor of, seeing how it is already going to take me 10 years to finish residency/fellowship).

Time to bumb this thread back.
http://www.washingtonpost.com/wp-dyn/content/article/2010/03/17/AR2010031704006.html

any new thoughts, developments?
 

dutchman

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If residents were paid by the hour, I am 100% sure programs/hospitals will be arguing in the oposite direction.
 
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