Never to Leave Hospital

Can You Learn Surgery While Watching the Clock?

One of the hospitals where I worked during surgical residency issued scrub shirts and pants emblazoned with the words “NEVER TO LEAVE HOSPITAL”. This warning was intended to prevent laundry theft and to discourage staff from wearing their gross work clothes to the grocery store after their shifts, but I often believed that it applied to me personally. I started surgical training in the late ‘90s, and the hours were brutal. Every third night on call in the hospital, routine 100-hour work weeks, never seeing the sun or feeling fresh air on my face for days on end. In 2003, halfway through my residency, came a rule change that affected me and residents in all medical specialties in the U.S.: the American College of Graduate Medical Education (ACGME) mandated that resident work hours be restricted to less than 80 hours per week, with other specific limitations on the number of consecutive hours that could be worked, as well as a requirement for at least one day off a week. The rationale for these restrictions was simple: fatigue leads to medical error, and by limiting the number of hours that residents spend on the job, the ACGME would improve both patient care and resident well-being. Life after these new rules was strange. Yes, it was nice to have more days off and more rest, but I couldn’t help feeling I was being short-changed in my surgical training by missing out on operations and leaving my patients in the care of another resident who only worked nights. On more than one occasion I was even sent home in the middle of surgery because I had exceeded my allotted time for consecutive hours worked.

The pros and cons of work-hour restrictions for surgical residents are in the news once more with the publication last week of the first multi-institutional prospective trial examining the effect of these regulations on patient outcomes. Karl Bilimoria, a surgeon at the Northwestern University Feinberg School of Medicine, led a study of 117 surgical training programs in the U.S. for the 2014–2015 academic year. Programs were randomized into two groups: the control group adhered to current ACGME restrictions, which cap resident work hours at 80 hours per week, with no more than 16 hours worked consecutively and at least 10 hours off between shifts. The other group was given more flexible boundaries, with no restrictions on maximum shift length or time between shifts. The maximum per week remained 80 hours, however. The flexible shift schedules were intended to prevent situations where a resident would otherwise be sent home and either miss out on an educational opportunity or negatively impact patient care. The results of the study, published in the New England Journal of Medicine, demonstrated no difference in patient outcomes in hospitals with and without flexible shift boundaries.

Bilimoria’s study has reignited existing debates regarding the value and meaning of work-hour restrictions for surgical residents. The fundamental questions remain: would you rather undergo an operation performed by a fatigued surgeon who knows you well, or a well-rested surgeon whom you’ve never met? Is it possible to learn the art and craft of surgery and take good care of complex surgical patients while simultaneously watching the clock? Numerous studies published since the adoption of the 2003 ACGME rules have demonstrated modest improvements in resident well-being, but none has shown any improvement in patient outcomes. By restricting resident shifts, we create a new set of problems related to patient handoffs. Patient care becomes a high-stakes game of Telephone between residents, with increased potential for errors as a result of communication failures and loss of critical information. Additional concerns center on the decline in resident education and performance resulting from restricted work hours. Data have emerged showing that a high proportion of current graduates of surgical residency are perceived to be less well-prepared to operate independently than in years past, and the majority of young surgeons now seek additional training after residency in order to further develop their skills. Many surgeons have placed the blame for this observed shift in competency and confidence on work-hour restrictions. Less time in the operating room means less exposure and experience. The complexity and scope of operations that need to be mastered continue to grow, and you can’t learn surgery from the sidelines.

I anticipate that many practicing surgeons (as well as residents) will take the results of Bilimoria’s study as proof that we never should have messed around with resident work hours in the first place. No news is good news, right? The fact that patient outcomes didn’t suffer with more flexible shift schedules will be interpreted by some as validation that the ACGME rules are arbitrary and meaningless. The cold reality remains, however: work-hour restrictions aren’t going anywhere. All of the training programs in the study still had to limit the overall resident work week to 80 hours. Surgery will never return to the bad old days, when residency was essentially indentured servitude, and admitting fatigue was a sign of weakness. Of all the medical specialties, surgery has had the hardest time adapting to the ACGME rules, because these rules threaten the very foundation of the surgeon’s professional ethos. One of the defining attributes of the surgical persona has been indefatigability, the ability to work through the night and then power through a whole slate of operations the next day. Surgeons have traditionally sacrificed sleep, food, creature comforts, and contact with loved ones in the name of taking the best care of their patients. The culture change required with implementation of work-hour restrictions was enormous: the dividing line between generations of surgeons is clearly demarcated by the year 2003, with old-school being those who trained before and new-school being those who have entered the field since. Ask any old-school surgeon and he or she will likely give you a variation on the same line: they don’t make ’em like they used to.

Many surgical educators have proposed and implemented creative solutions to address the educational gaps created by work-hour restrictions. The technology of surgical simulators has advanced remarkably in the past decade, and simulation work has been shown to help better prepare novice surgeons for cases. Online videos and training modules that can be viewed at home during off-duty hours have become staples of residency curricula. Every surgeon knows the fundamental truth, however: there’s no substitute for the real thing. Hands-on training in the operating room and in the hospital wards remain the best ways for surgical residents to learn, and these are the unwitting victims of inflexible ACGME rules. Surgeons like to consider themselves the ultimate problem-solvers, but in striving to find the ideal balance between patient safety, resident well-being, and surgical education, we are clearly still trying to figure things out.