imageBy George Ochoa

The majority of general surgery residents are concerned about the 16-hour duty limitation for postgraduate year 1 (PGY-1) residents, according to a study presented at the American College of Surgeons’ annual Clinical Congress in Chicago, and published online on October 5 (J Am Coll Surg doi: 10.1016/j.jamcollsurg.2012.08.005).

Implemented by the Accreditation Council for Graduate Medical Education effective July 1, 2011, the duty period limitation was intended to minimize fatigue and decrease the frequency of errors. But overall, 75% of general surgery residents in the study voiced dissatisfaction with this limitation.

“The 16-hour duty restriction was implemented for the PGY-1 class without a whole lot of data supporting its benefits and patient safety,” lead author David Y. Lee, MD, general surgery resident (PGY-4), Department of Surgery, St. Luke’s-Roosevelt Hospital Center, in New York City, told General Surgery News.

“We wanted to see what general surgery residents have to say about it.” The key finding, he said, was that “most of the residents are very concerned that it will have a negative impact.”

The anonymous web-based survey was distributed via program directors of 233 publicly listed general surgery residency programs across the nation. Only fully completed surveys (N=464) were analyzed. Eighty-seven percent of all respondents believed the 16-hour duty limitation had an adverse impact on the learning of the PGY-1 class, and 57% believed it contributed to inadequate patient sign-outs. Seventy-six percent of residents reported problems caused by inadequate sign-outs, and PGY-1 residents performed more sign-outs than their senior colleagues.

More PGY-2 to PGY-5 residents than PGY-1 residents noted dissatisfaction with the duty limitation and expressed more concern about its educational impact. Eighty-nine percent of PGY-2 to PGY-5 residents believed the duty limitation had shifted more responsibilities to them from the PGY-1 residents; 73% felt more fatigued because of this shift; and 86% detected a decrease in the level of patient ownership.

“There is an increasing body of knowledge that duty-hour limitations are not working,” said L.D. Britt, MD, MPH, FACS, FCCM, Brickhouse Professor and chairman, Department of Surgery, Eastern Virginia Medical School, in Norfolk, who was not associated with the study. “Not one metric has been improved by duty-hour limitations. This article addresses the most recent modification, the 16-hour duty limitation. It shows a shift in responsibility from interns to senior residents and an increase in handoffs.”

Dr. Lee said the study’s main shortcoming was its survey-based nature. “It doesn’t include objective data on medical error.” Dr. Britt added, “The downside of the article is that less than 10% of the residents responded. There could be a selection bias. However, I do think it reflects broader attitudes.”

Alexey Markelov, MD, chief surgical resident, Easton Hospital, Drexel University College of Medicine, in Easton, Pa., who was not associated with the study, commented by email. “I am particularly concerned about the potential negative impact on surgery residents due to limited time to acquire the necessary surgical proficiency and skills,” Dr. Markelov wrote. “There is also a plausible concern that 16-hour duty limitation profoundly impacts continuity of care. New limitations make it almost impossible for general surgery residents to follow up with a single patient through preoperative evaluation, surgery and postoperative care.”

“Surgery is like an apprenticeship,” said Dr. Britt. “You have to be exposed to patients. It’s hard doing that when you’re at home. … For our specialty, which is surgery, so far the duty-hour limitation doesn’t work.”