Many studies demonstrate that it takes 10,000 hours or 10 years of repetition to master a skill. In the surgical specialties of medicine, in order to complete training with competence, a resident/fellow needs to gain knowledge and skill in a very short period of time (5-7 years of training after medical school). Concerns over resident work weeks, which had been as long as 120 hours including long shifts (36 hrs working, then 8 hrs off, then back for 36 hrs again- and repeat) led the ACGME to mandate that residents can work no more than 80 hour per week. This was thought to enhance patient care and minimize complications/errors from tired residents. However, the unintended consequence was inadequate training resulting in graduating physicians without the requisite skill and knowledge to handle stress, complicated cases or the difficult surprises that await doctors when treating patients in the “real world”. This recent study and report demonstrate that this topic must be revisited so that we can continue to educate our future physicians properly, so they are ready to care for patients without supervision upon graduation and provide the highest quality of care possible.
Surgery patients fared just as well when junior doctors worked longer than mandated hours in the first major rigorous test of regulations many physicians say hurt medical education.
Nationwide limits on work hours were established more than a decade ago because of concerns that sleep-deprived medical residents were a threat to themselves and their patients. To test that, researchers randomly assigned more than 4,000 surgery residents to regulation hours or a more flexible schedule that allowed them to continue with a case after their shifts ended. That sometimes meant working for more than 28 hours at a time.
The study looked at how many patients died or had serious complications in the month after surgery and found the same rate — about 9 percent — in both groups. Residents’ self-rated dissatisfaction with their education and with their well-being were similarly low — 11 percent and roughly 13 percent, respectively, in each group.
It’s a landmark study, testing “a hot button, controversial issue in health care,” said lead author Dr. Karl Bilimoria, director of surgical outcomes and quality improvement at Northwestern University’s Feinberg medical school. Without flexibility, rookie doctors often have to end their shifts in the middle of caring for patients, handing them off to another medical resident, Bilimoria said.
“Our hope would be that the evidence would be used … to change policies fairly soon and allow flexibility back into surgical residency,” he said.
Residents’ work limits were first set in 2003 by the Accreditation Council for Graduate Medical Education, and revised in 2011. The rules include 80-hour maximum workweeks.
The group said it will consider the results as part of an ongoing review of residents’ work hour standards. The council, the American College of Surgeons and the American Board of Surgery paid for the study, which was published Tuesday by the New England Journal of Medicine.
A Mayo Clinic neurosurgery resident, Dr. Maya Babu, said the study results were not at all surprising. She’s head of an American College of Surgeons’ residents group.
Under the limits, Babu said she has sometimes had to clock out at inopportune times, even in the middle of brain tumor operations, missing important learning opportunities. She said if allowed flexible hours, most residents would know when to speak up and say they’re too tired to continue working.
Dr. John Birkmeyer, a surgeon and health outcomes policy expert at the Dartmouth-Hitchcock Medical Center, said in a journal editorial that the study “effectively debunks concerns that patients will suffer as a result of increased handoffs and breaks in the continuity of care.” But Birkmeyer advocates medical training that doesn’t “depend on overworked resident physicians.”
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