In 1904, Dr. William S Halsted delivered a lecture at Yale entitled “The training of the surgeon” in which he described the merits of the way in which surgeons were being trained in Germany. He pointed out that the assistants or “residents” in those programs enjoyed good research facilities, ample clinical material, and excellent instruction. Having been appointed professor of surgery at the newly opened Johns Hopkins Hospital in 1892, he described his plan to adopt the German method for training surgeons to the program he would establish in Baltimore. Through his own 17 residents and more than 50 assistant residents who took positions in other states, he established the concept of academically oriented training programs, which became the accepted standard throughout the country. Over the years, surgical training programs proliferated and reached a peak of 723 in 1959. To provide quality assurance for these programs, the Residency Review Committee was established in 1950 and composed of representatives from the American College of Surgeons, the American Board of Surgery and the American Medical Association. Just as the American Board of Surgery examines individuals to assure that their experience and judgment can qualify them for certification as competent surgeons, so the Residency Review Committee examines institutional training programs to be certain that they meet the educational and environmental requirements to provide the necessary training. The Residency Review Committee for Surgery is itself responsible to the Accreditation Council for Graduate Medical Education (ACGME) which has board representation from the American Board of Medical Specialties, the American Hospital Association, the American Medical Association, the Association of American Medical Colleges and the Council of Medical Specialty Societies. It sets the standards for work environment, education, supervision, patient care responsibilities and other competencies for 7,800 programs in 110 specialties and subspecialties. By enforcing high standards for education and the training environment over the past 20 years, the surgery RRC has reduced the number of training programs to 252, of which approximately 25% come up for review annually.
One of the major concerns of the RRC-S at the present time is the issue of resident duty hours. This came to public attention after the sensationalism surrounding the 1984 death of an 18-year-old woman at the New York Hospital who had concealed her use of drugs and died from a subsequent drug interaction. The family felt that house staff fatigue was an issue and since the father was a well known journalist, a commission was appointed, chaired by Dr. Bertram Bell, to investigate and advise the state [1]. The result was the “Bell 405 regulations” which mandated that residents be on call no more than 80 hours per week, work no more than 24 consecutive hours and have a minimum of 8 hours between duty assignments. When investigators found laxity in compliance with the rules, heavy fines were levied against the institutions. On April 30, 2001, a petition was submitted to the Occupational Safety and Health Administration (OSHA) from the AMA’s student and resident committees joined by Ralph Nader’s Public Citizen. Further support for national restrictions has come from the AMA Board of Trustees and from several state legislatures. The AAMC added its endorsement in October 2001, with publication of their policy recommendations which added further restrictions of no more than 12 hours of continuous duty in high intensity settings, such as emergency rooms and critical care units. In November 2001, Representative John Conyers, Jr. (D-Michigan) introduced the Patient and Physician Safety Protection Act of 2001 in the House of Representatives that included the same list of restrictions.
This issue has not been kept under the rug. The Residency Review Committee for Surgery has a long history of concern about resident workload and the working environment. Current requirements include the provision that residents be on call no more than every third night and have at least 1 day out of 7 free of routine responsibilities. In addition, the teaching hospital is required to provide sufficient support personnel to avoid the need for residents to perform noneducational tasks, and program directors are required to justify the clinical workload if a finishing resident reports more than 1,500 total operative cases. A proposal by the RRC to strengthen the requirements was placed on hold last year by the ACGME pending a formal agreement on duty hour limitations for all specialties. Under the current regulations, of the 61 general surgery programs reviewed by the RRC last year, 18, or 30%, were cited for work hour violations and an additional four were cited for environmental problems. The program director is now required to respond immediately to the citation with a progress report providing a plan of action for remediation.
The RRC has not imposed a weekly limit on duty hours since circumstances and definitions vary, such as hours of sleep on call, effects of resident illness or pregnancy leave, attendance at medical meetings, variable availability of donor organs, unpredictable trauma and disaster events, and the importance of follow-up of complications requiring reoperation. The primary concern of the RRC is the negative impact that excess fatigue has on resident education rather than as a risk to patient safety. Residents who cannot stay awake during a teaching conference obviously do not benefit from it. But fatigue is a common problem among many practicing physicians in all specialties. It is also clear that other factors besides long hours and sleep deprivation lead to fatigue and stress. For surgery residents, the shift to ambulatory care and outpatient procedures for routine patients has made the inpatient population much more complex. In addition, financial cutbacks in teaching hospitals have increased paperwork requirements and led to excessive paging, delays in order fulfillment, and overall scut work. With fewer nurses available and less well trained substitutes, overwork of all health professionals has significantly increased. Additional problems for the resident include their high level of indebtedness leading to pressures to moonlight, their family obligations and expectations and the deterioration of the educational environment and teaching as attending surgeons face their own pressures to become more cost effective and clinically productive. Today, most residents marry or have partners who can either be supportive or actually contribute to their stress.
In contrast to most assumptions, the results of limiting work hours can actually lead to an increase in the rate of adverse events and complications. Studies have shown that preventable errors are strongly associated with coverage of a medicine service by another team and that patients are significantly less satisfied with their care by a medicine “night float” system [2]. Another case-control study of more than 3,000 patients in an urban teaching hospital showed that increasing cross-coverage led to a significant increase in potentially preventable adverse events. These events were more than twice as likely to occur in patients covered by an intern from another team or night float resident than matched controls in adjacent beds (26% versus 12%, P <0.05) [3]. Similarly, limiting work hours in surgery without correcting other sources of stress has been tried. Danish surgical educators report “… a terrible situation. We are producing a whole generation who are poorly equipped both clinically and technically” [4]. In contrast graduate education in this country sets the standard for the world with many trained surgeons from abroad anxious to repeat their training here. The hallmark of this experience is a commitment to patient care without regard to time, day of the week, hours worked or on call schedule. It is the patient’s welfare that comes first. But as stated in the RRC requirements, patients have a right to expect an alert, responsible and responsive physician able to deliver effective and appropriate care.
In response to the current concerns, the Executive Director of the American College of Surgeons, Dr. Thomas R. Russell, recently stated “the imposition of arbitrary work hours that by law must cease at a certain time does not provide a constructive framework for instilling or developing a value system in young surgeons. Constrained work hours do not prepare residents for the real word of surgical practice and the American College of Surgeons is deeply concerned about the passage of such legislation that would affect work hours, particularly when it sets up barriers to learning.” In further support of this concept, the Society of University Surgeons has issued a position paper echoing the concern regarding the narrow focus of restriction of resident work hours rather than improvement of the overall resident educational system and environment. It has made the following recommendations:
1. Adequate metrics need to be conceived and implemented to measure the three parameters that are at the crux of this issue; namely, the quality of resident learning, the quality of patient care, and the use of resident time in noneducational activities. It is only with these tools that one can adequately monitor, modify and optimize the resident work environment.
2. Budgetary concerns in teaching hospitals have often caused reductions in support personnel so that residents are expected to perform duties that others should do. It is clear that this inappropriate use of residents’ time and skills may be a major reason for long training hours at night. Adequate information concerning noneducational activities currently imposed on residents needs to be gathered and used to eliminate these unnecessary tasks with the goal of reducing duty hours.
3. Arbitrary limitations on educational hours of training will increase resident stress, adversely affect the welfare of the surgical patient and may result in the need to lengthen an already long period of graduate surgical education. Correction of problems in the educational environment and positive programs to address resident stress prevalent in today’s teaching hospitals are urgently required.
4. The Residency Review Committee should be strongly supported in its actions to enforce the standards for the working environment. Adverse accreditation action should occur when repetitive patterns of work hour violations are documented.
5. The role of the teaching surgeon needs to transcend that of merely supervision to that of mentorship. The relationship of resident and attending staff should be mutually supportive with education as the primary goal and exemplary patient care as its cornerstone. Residents should be treated with respect and dignity and should in turn demonstrate personal attributes of honesty, diligence and responsibility. The impetus for lifelong self-learning must be strong.
6. Initiatives to provide relief for student-incurred debt should be explored and developed. The impact of moonlighting on overall levels of fatigue may contribute to resident stress and adversely affect performance.
7. New educational models need to be explored and developed that would allow for more effective teaching and utilization of resident time. Application of the educational model should enable surgical programs to establish uniformity and well defined curricula with an expanded formal education process that allows for the precise assessment of progress.
8. There must be an adequate level of funding to provide for the costs of physician facilitators, remediation of hospital staffing deficiencies, to support the research required to stimulate the development of new educational models and to pay for the implementation of costly surgical residency educational tools. Current shrinking clinical revenues and reduced hospital reimbursements do not allow for such funding. The deficiencies need to be acknowledged so that they can be addressed at institutional, state, and federal levels.
Another constructive approach to the working hours conflict by improved data collection has been proposed by the American College of Surgeons and funded by the Agency for Health Care Research and Quality. The study is a collaborative project among the Human Factors Project in Austin, Texas, the VAMC Cooperative Studies Program in Hines, Illinois, and the Chicago Association for Research and Education in Science. It is designed to study the performance of residents in surgery and anesthesiology related to patient safety. It will involve 90 VA teaching hospitals and three nonfederal university hospitals currently enrolled in the NSQIP. Using a survey approach, the study will identify all factors in the work environment that contribute positively or negatively to resident performance. It will correlate adverse events and errors, risk adjusted with the working environment.
By addressing most causes of fatigue and stress in the teaching environment, resident duty hours should disappear as an independent issue in favor of an enhanced educational environment. Assisted by qualified personnel, residents will work reasonable hours to care for patients, learn their craft, and become skilled practitioners. Of critical importance, the fundamental precept of patient welfare having the highest priority will not be sacrificed and residents will learn to watch the patient and not the clock. As a result, patient care and satisfaction will improve and the likelihood of errors will be reduced.
Suggested reading
Polk HC, Taylor RJ, editors. Proceedings of the “Challenges in surgical education: competencies, work hours, and workforce. Assessment and adaptation” symposium. Am J Surg 2002;184:185–253.
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