Monday, June 14, 2004

From this month's Journal of the American College of Surgeons: Viewpoints from generation X: a survey of candidate and associate viewpoints on resident duty-hour regulations

Recently, the controversy over prolonged resident duty hours has gained national attention. In 2000, the Institute of Medicine report To err is human. Building a safer health system reported that medical errors result in more than 1 million patient injuries and 98,000 patient deaths each year.1 The Institute of Medicine report explored many possible contributors to medical errors. Of interest to the current debate, it stressed the need for a greater understanding of the relationship between physician workload and work hours to resultant fatigue, alertness, and sleep deprivation.

In 2001, the American Medical Student Association, the Committee of Interns and Residents, and Public Citizen petitioned the Occupational Safety and Health Administration for national resident duty-hour limitations to protect residents. They argued that prolonged resident duty hours placed residents at increased risk for motor vehicle crashes, obstetric complications, and poor mental health.2 Subsequently, Rep John Conyers Jr (D-MI), and Sen Jon Corzine (D-NJ) introduced The Patient and Physician Protection Act of 2001 (HR 3236)3 and The Patient and Physician Protection Act of 2002 (S 2614).4 The Patient and Physician Protection Acts called for federal limitation of resident duty hours to 80 hours per week. To preempt the federal government involvement in the regulation of resident duty hours, the Accreditation Council of Graduate Medical Education (ACGME) implemented duty-hour guidelines that limit resident duty hours to 80 per week, in-hospital call to no more frequent than every third night, and one full (24-hour) day free of patient care, all averaged over a 4-week period.5 The ACGME defines duty hours as all clinical and academic activities related to the residency program (ie, patient care [both inpatient and outpatient], administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences). Duty hours do not include reading and preparation time spent away from the duty site.

There has been a great deal of controversy over resident duty hours and the ACGME implemented changes, but the literature is limited with regard to the viewpoints and attitudes of surgery house staff with respect to the implemented changes. The objective of this study was to evaluate the viewpoints and attitudes of surgical residents and staff physicians as they pertain to the national duty-hour guidelines.

So they surveyed the particpiants in the Candidate and Associate Society at the 2001 Clinical Congress. Here is how they broke down:

Sixty-nine percent agreed and 23% disagreed that resident on- call shift should be limited to no more often than every third night. Thirty-six percent agreed and 47.1% disagreed that residents should have a minimum of 10 hours off-duty time between shifts. Twenty-seven percent agreed and 64.7% disagreed that resident duty hours should be limited to 24 consecutive hours worked in one shift. Fifty percent agreed and 41.4% disagreed that the number of hours residents are allowed to work per week (7 days) should be limited. Twenty-five percent agreed and 62.1% disagreed that, in an effort to reduce duty hours, as the day progresses residents should have mandatory limited responsibilities. For example, if not on call, residents should not be sent to the operating room or given new patients after 4 . Twenty-five percent, 63.4%, and 11.0% of respondents reported that residents should be allowed to work, on average, ≤80 hours per week, 81 to 100 hours per week, and > 80 hours per week, respectively

So in a nutshell, surgery residents think that they should not be on call more than Q3,but when on call should not be required to leave the hospital post-call at a certain time. A majority believe that a 81 to 100-hour workweek is reasonable.

The discussion is fun to read:

Sociologists have previously described surgeons as individuals who, to save human life, are pragmatically oriented, take decisive action, and display value patterns and behaviors that are emblematic of the “hero” in American society.6,7 This perspective has been propagated by the presentation of surgeons in popular television programs such as Ben Casey, MASH, St Elsewhere, and ER, just to name a few. To live up to the societal and surgical cultural demands and expectations of the “hero,” surgical residents work long and grueling hours

Saddest day of my residency was when I had to turn in my tights and cape.

As Europe plans to implement a 48-hour resident workweek, the debate over the optimal resident duty hours in this country will continue.8,9 Surgical residency training is often considered the poster child of resident duty-hour abuse.10,11 As supporters of duty-hour limitations fight to liberate surgical residents from their “self-imposed servitude,” our findings suggest that surgical residents may agree with those who believe limiting duty hours to ≤ 80 hours/week will have a deleterious effect and should not have been implemented.12 It is unclear if this viewpoint is a reflection of perceived educational needs or surgical culture.

That is no misprint, gentle reader, Europe is going to a 48 hour workweek. Did the same thought process that believed that if the overall workweek was shortened then more workers would have to be hired come up with this plan? This survey does have some limits:

Our study population consisted of a predominance of senior residents, men, and those from university training programs; so we may have underestimated the overall proportion of residents who agree with duty-hour limits.

Another possible explanation for the difference in our results compared with previous work is that attendees of the ACS-CAS Forum are more likely to agree with the published official statement of the American College of Surgeons, which strongly disagrees with duty-hour limits.9,14 A large, more representative, study is required to fully understand the viewpoints of surgeons with regard to resident duty-hour limits and determine if support for duty-hour limits differs between resident and staff physicians.

The final verdict on work-hour limits is going to be years in arrival, as the impact won't be truly felt until residents trained under the restrictions graduate and begin to practice. My personal opinion is that the current system of work-hour limits creates an artificial environment that may not hold up in the real world.

See previous posts on the subject here, here, and here.
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