Surgical training and duty-hour limits: an oxymoron or an idea whose time has come?

At a national meeting a little more than two years ago, I watched as a plenary session unfolded on the subject of the Accreditation Council for Graduate Medical Education's duty-hour rules. (1) The chair of the Residency Review Committee of a major surgical subspecialty, a prominent national figure, stood at the podium and inveighed against the ACGME's new requirements limiting duty hours. He said that doctors are not truck drivers or airline pilots; we are fundamentally different types of people. He stated that we can tolerate sleep deprivation without compromising our ability to function, in ways that other people simply cannot do, and that we are a self-selected population, able to withstand fatigue and train ourselves to perform difficult cognitive and technical tasks under the most exhausting circumstances, with no detriment to ourselves or to our patients.

Oh, really?

Those of us who trained in "the days of the giants" recall frequent 36-hour shifts, entire weekends on call, and falling asleep on our feet. The culture of medical training encouraged us to think of those days as "glory days," and the ability to push through bone-crushing fatigue was seen as a sign of strength. However, in 1984, the death of 18-year-old Libby Zion from a drug reaction in New York City while under the care of an intern ignited a firestorm of debate about the long hours worked by medical trainees. This public debate continues today, and the ACGME duty-hour policies were formed largely in response to ongoing public concern about overtired residents and the resulting potential impact on patient safety. The implementation of the mandatory 80-hour work week in July 2003 was, and continues to be, a subject of intense controversy in the field of graduate medical education. However, recent data on cognitive and technical performance in sleep-deprived individuals force us to reconsider our long-held beliefs.

It has been suggested that sleep should be considered the "new vital sign." (2) There is rapidly mounting evidence that sleep deprivation leads to significant functional impairment. Cognitive psychomotor performance decreases after 24 hours of wakefulness to a level equivalent to that observed with a blood alcohol level of 0.10%. (3) Limiting extended intern work shifts in an intensive care setting has been shown to significantly decrease attentional failures, as measured by continuous electroculography. (4) It also has been reported that interns who work extended shifts of [greater than or equal to] 24 hours more than double their risk of being involved in a motor vehicle accident, (5) and that sleep-deprived residents had a significantly increased incidence of technical errors in the performance of simulated laparoscopic surgery. (6) This is but a sample of the many studies documenting the detrimental effects of sleep deprivation.

The data supporting the negative effects of fatigue on cognitive and technical performance are irrefutable, but some still contend that fatigue has never been shown to adversely affect patient care. Despite mounting evidence that the inhumane practice of working residents until they drop is both educationally ineffective and unsafe for patients, our system of resident education has remained essentially unchanged from the late 1890s, when William Halsted introduced the concept of "residents" (junior doctors who lived in the hospital), until July 2003.

Despite protestations to the contrary, doctors are affected by fatigue, and the evidence shows that we must change the way we train residents. There are, however, legitimate concerns about how duty-hour limitations affect the quality of education we provide. These concerns center on continuity of care, development of professionalism and, in the surgical fields, residents' caseloads during their training.

Although a number of studies have attempted to assess the effect of the ACGME duty-hour rules on the quality of resident education, these studies have not shown consistent results. It appears that resident morale is enhanced, but there is concern about continuity of care, patient handoffs, and reduction of educational programming. (7,8) With careful planning of resident schedules, it may be possible to mitigate the effect on resident caseloads, but there are significant obstacles to maintaining case volume. (9-11) With the exception of a recent study demonstrating that a reduction of extended intern work shifts in intensive care settings resulted in a significant decrease in serious medical errors, (12) minimal evidence exists to clarify the impact of duty-hour limits on patient care. We find ourselves in the unenviable position of knowing that fatigue impairs performance but not knowing the impact that restricting duty hours will have on the quality of our training programs or on patient care.

As institutions gain experience in instituting systems of care delivery that do not depend upon a single individual being in place for 36 hours at a stretch, and as programs gain experience in developing resident-scheduling strategies that minimize scut work, prevent redundancy, and maximize educational experience both in and out of the operating room, we will begin to see more clearly what 80 hours a week can buy for us in terms of training and patient care. Only then will we know whether we can train surgeons in a humane 80 hours per week, given the current length of our residency programs, or whether we will need to increase the length of our training programs to give residents the necessary experience while allowing them time to sleep.

CYNTHIA G. SILBER, MD, FACOG Associate Dean for Graduate Medical Education Jefferson Medical College Thomas Jefferson University Philadelphia

References

(1.) ACGME Web site, accessed June 13, 2005: www.acgme.org.

(2.) Wilson J JF. Is sleep the new vital sign? Ann Intern Med 2005; 142:877-80.

(3.) Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature 1997;388:235.

(4.) Lockley SW, Cronin JW, Evans EE, et al. Effect of reducing interns' weekly work hours on sleep and attentional failures. N Engl J Med 2004;351:1829-37.

(5.) Barger LK, Cade BE, Ayas NT, et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med 2005;352:125-34.

(6.) Eastridge BJ, Hamilton EC, O'Keefe GE, et al. Effect of sleep deprivation on the performance of simulated laparascopic surgical skill. Am J Surg 2003;186:169-74.

(7.) Barden CB, Specht MC, McCarter MD, et al. Effects of limited work hours on surgical training. J Am Coli Surg 2002; 194:531-8.

(8.) Reiter ER, Wong DR. Impact of duty hour limits on resident training in otolaryngology. Laryngoscope 2005;115:773-9.

(9.) Mendoza KA, Britt LD. Resident operative experience during the transition to work-hour reform. Arch Surg 2005; 140:137-45.

(10.) Hassett JM, Nawotniak R, Cummiskey D, et al. Maintaining outcomes in a surgical residency while complying with resident working hour regulations. Surgery 2002; 132:635-41.

(11.) Jarman BT, Miller MR, Brown RS, et al. The 80-hour work week: Will we have less-experienced graduating surgeons? Curr Surg 2004;61:612-15.

(12.) Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004; 351:1838-48.