By Victoria Stern

To what extent are work hour restrictions adding to the burden of surgeons-in-training? Despite heated debate for over a decade, surgeons and policymakers have come no closer to a consensus. 
In 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted work hour restrictions of 80 hours per week, except under very special circumstances when a program or surgeon-in-training could be granted an additional eight hours of training per week. [The up-to-date 22-page ACGME document, detailing criteria for surgical residency requirements, can be found here.]
Before this, residents and interns often trained over 100 hours every week. Policymakers and medical experts became concerned that these grueling weeks caused a significant increase in serious medical errors. A pivotal study in the New England Journal of Medicine found that sleep deprivation was the main culprit behind these medical errors (N Engl J Med 2004;351:1838-1848). That data seemed to seal the deal. Work hour restrictions became an integral part of medical training. 
But after implementing the ACGME’s policy, another crop of concerns emerged. Over the last two years, a growing body of research has shown the potential dangers of such work hour restrictions, with the majority of studies finding that more and more surgical residents feel unprepared to practice surgery while training a maximum of 80 hours per week. Even now, the controversy surrounding this decision persists with recent articles in General Surgery News and The New York Times, detailing the negative repercussions of work hour restrictions. 
Although sleep deprivation, and consequently medical errors, is a serious concern, another equally relevant issue is whether or not surgeons have enough time to learn the necessary techniques and technologies. As a group of expert surgeons explained, part of the problem is the ever-expanding array of new techniques and technologies young surgeons must master, which now must be shoved into an even smaller training window (Ann Surg 2013;258:440-449). The authors wrote: “The rapid adoption of new technologies, the integration of advanced minimally invasive techniques, and the exponential expansion of the knowledge and variety of procedures that trainees must learn have coalesced to dramatically and permanently alter the landscape of surgery. In many cases, these rapid changes overwhelm the ability of surgeons to readily adopt and master new techniques. Many surgery training programs also struggle to effectively integrate new procedures and technologies into residency curricula. Yet increasing demand by the public and hospital administrators has pressured surgeons to seek proficiency in all these new procedures.”
In this study, fellowship program directors across the United States completed electronic surveys assessing how prepared their general surgery trainees were when entering accredited surgical subspecialty fellowships. Of the 91 respondents, over 40% reported that new fellows could not “perform 30 minutes of a major procedure independently on arrival to fellowship” while 30% of programs directors said new fellows could not independently and safely perform basic operations, such as a laparoscopic cholecystectomy. Additionally, 32% reported new fellows lacked proficiency in a variety of technical skills, most notably in laparoscopic suturing. 
It was only after surgeons-in-training finished their fellowships that program directors felt they had acquired the necessary skills to practice. By the end of the fellowship, over 80% of program directors said that their fellows could perform advanced cases and practice independently. 
Another recent study in the New England Journal of Medicine, which supports the idea that practice makes perfect, found that surgical skill was not related to years in bariatric surgery practice, but to procedure volume. After reviewing videotapes of operations performed by 20 bariatric surgeons (who remained anonymous), those judged as having the best technical skill performed almost three times the number of laparoscopic gastric bypass procedures annually (53 vs. 157, P=0.005) and more than two times the number of any bariatric procedure (106 vs. 241, P=0.02) compared with the bottom-rated surgeons. Surgeons who performed the most procedures also boasted shorter average operating times and fewer postoperative complications. 
But the news may not be all bad. Certainly, for some, the current residency guidelines appear to be adequate. For instance, a 2014 study, which surveyed general surgery chief residents throughout the United States, found that “current graduates of general surgery residencies appear to be confident in their skills,” with less than 10% of the 297 respondents feeling uncomfortable performing a laparoscopic colectomy (7%) or colonoscopy (6%) (J Am Coll Surg 2014;218:695-703). 
Still, it’s hard to deny the link between a surgeon’s operative skill, the volume of procedures performed and patient outcomes. With the work hour restrictions, surgeons estimate that training surgeons may participate in just two or three operation a week, as opposed to one per day, as was the case a decade ago, and that trainees now lose about a year’s worth of experience. 
And should it be concerning that about twice as many graduating general surgeons are failing their American Board of Surgery Certifying Examination now (about 30%) as opposed to over a decade ago (15%)? Could the work hour restriction policy also help explain why more surgeons are choosing to pursue fellowships after residency? (See here and here, for more insights on the concerns over work hour restrictions).
So, the question remains, how can we reconcile the need for surgeons to have adequate exposure and practice throughout their training with the understanding that sleep is also paramount to good results? Should residency programs be extended one year to make up for the time lost due to restricted work hours? Should we keep work hour restrictions, but make them less restrictive (say cap it at 90 hours per week) or is it better to just do away with them entirely? 
Perhaps, we are looking at the training landscape the wrong way, trying to find a single solution that will satisfy everyone. Instead, what if we tailored residency programs to the individual surgeons’ needs over the course of their training, instead of creating blanket restrictions and guidelines that apply to all? Of course, such a plan would be much more difficult to implement and would require careful attention to each trainee, but at least this would help ensure that no person is left behind.
Surgical training is exceptionally demanding and complex, and thus it may require an equally multifaceted approach to training.