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The Ongoing Decline of Resident Education

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Skeptical Scalpel

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last three years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 1400 page views per day, and he has over 8300 followers on Twitter.

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Skeptical Scalpel (click to view)

Skeptical Scalpel

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last three years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 1400 page views per day, and he has over 8300 followers on Twitter.

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In both medicine and surgery, the 16-hour work restriction has resulted in unintended consequences.

A paper from Johns Hopkins looked at traditional, every fourth night calls compared to reduced-hours interns working staggered shifts of an every fifth night call or “night float.”

“Night float” means working a shift that begins in the evening and ends in the morning, typically 8:00 PM to 8:00 AM.

The study found that although interns working on the “night float” or every fifth night shifts got significantly more sleep than the control group of interns working longer shifts every fourth night, “both the every fifth night and night float models increased hand-offs, decreased availability for teaching conferences, and reduced intern presence during daytime work hours. Residents and nurses in both experimental models perceived reduced quality of care, so much so with night float that it was terminated early.” [Emphasis added]

A JAMA Surgery paper received far less attention but had a similar theme. It surveyed 213 surgical interns from 11 university hospitals in July 2011 and May 2012 (the first academic year that the new 16-hour limit was in force).

Although 82% of the interns reported a neutral or good quality of life, more than one-quarter had symptoms of emotional exhaustion and depersonalization, and 32% said their work-life balance was poor. Two-thirds said they thought about their satisfaction with being a surgeon daily or weekly, and 14% said they considered dropping out of surgery training at least weekly.

More than half of the residents said that the work-hour changes had decreased their time spent in the operating room. At the end of their intern year, 44% said they did not believe that the work-hour limits led to reduced fatigue.

So, in both medicine and surgery, the 16-hour work restriction has resulted in unintended consequences.

As if that is not bad enough, check out this blockbuster: The title of a paper in Annals of Surgery is “General Surgery Residency Inadequately Prepares Trainees for Fellowship: Results of a North American Survey of Program Directors.” General surgery subspecialty fellowship directors were surveyed, and 91 (63%) responded.

From the paper: “21% [of fellowship program directors] felt that new fellows arrived unprepared for the operating room, 38% demonstrated lack of patient ownership, 30% could not independently perform a laparoscopic cholecystectomy, and 66% were deemed unable to operate for 30 unsupervised minutes of a major procedure. With regard to laparoscopic skills, 30% could not atraumatically manipulate tissue, 26% could not recognize anatomical planes, and 56% could not suture. Furthermore, 28% of fellows were not familiar with therapeutic options and 24% were unable to recognize early signs of complications.” [Emphasis added]

Note that the residents in the Annals paper had not yet been subjected to the 16-hour work limits, as that rule was not in effect when they were first-year trainees.

The good news is that by the end of their fellowship training, 82% could perform advanced cases independently. There was no word on the fate of the 18% who could not perform advanced cases independently. Now that’s reassuring, isn’t it?

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last three years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 1400 page views per day, and he has over 8300 followers on Twitter.

4 Comments

  1. A general/trauma surgery attending at my local Gen Surg residency said that in order to practice Gen Surg after graduating, residents should complete a fellowship in Gen Surg, AFTER completing a Gen Surg residency.

    Reply
  2. This is an interesting topic that I admit I have no background or insight into. If this reduced-hours system is not working well, what is the solution? Is it best to go back to the previous every fourth night call system or is there a third option? It seems like there must have been problems with the traditional system if it prompted a change in the first place.

    Thanks in advance to anyone willing to answer my basic question.

    Reply
    • Dan, it’s a good question. The work hours rules were established because they seemed like a good idea. There was very little evidence that they would work. As I noted in the post, there have been unintended consequences. There is a study about to begin involving a large number of general surgery programs. The control group of programs will be the way the hours are now. The experimental group will be allowed to develop flexible hours within certain limits. Patient outcomes will be assessed. Here’s a link to the description of the study http://clinicaltrials.gov/ct2/show/NCT02050789?term=residents&rank=8.

      Reply

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