The impact of reduced work hours on residents
The new ACGME work hours restrictions are causing problems across the board.
Everyone has read about the paper from Johns Hopkins that appeared this March in JAMA Internal Medicine. It was a study of traditional every fourth night call compared to reduced hours interns working staggered shift of every fifth night (Q5) call or "night float" (NF).
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 Q5 and NF 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 NF that it was terminated early."
A paper from JAMA Surgery in January received far less attention but had a similar theme. It surveyed 213 surgical interns from 11 university hospitals in July of 2011 and May of 2012. This was 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 a quarter of them 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.
Over half of the residents said that the work hours changes had decreased their time spent in the operating room, and at the end of their intern year, 44% said they did not believe that the work hours 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 an abstract presented at the recently concluded American Surgical Association 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. Of course the abstract gives few details but program directors say that of new fellows (that is, graduates of five-year general surgery training), 30% could not perform a laparoscopic cholecystectomy by themselves and 66% were not able to operate without supervision for half an hour during a major case.
Large numbers of new fellows were judged unable to perform some routine technical skills associated with laparoscopic surgery. About 25% did not know what therapeutic options were available or how to tell when early signs of complications were present.
Now that's reassuring, isn't it?
Skeptical Scalpel is a recently 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 two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 900 page views per day, and he has over 5700 followers on Twitter.