Shorter Surgical Shifts Result in Less Training

The restriction of work shifts for general surgery residents to a maximum of 16 hours has resulted in reduced operative experience, according to a new study.

Researchers at Harbor–UCLA Medical Center (Torrance, CA, USA), the University of Hawaii at Manoa (Honolulu, USA) and other institutions conducted a retrospective review of categorical postgraduate year one case logs of 249 categorical general surgery interns; the study included 52 residents from the intern class with a 16-hour work limit, and 197 residents without the 16-hour work limit from the four preceding years. A total of 10 general surgery residency programs in the western United States were included. Main outcomes included total, major, first assistant, and defined-category case totals.

The results showed that compared with the preceding four years, the 2011–2012 interns recorded a 25.8% decrease in total operative cases, a 31.8% decrease in major cases, and a 46.3% decrease in first-assistant cases. There were statistically significant decreases in cases within the defined categories of abdomen, endocrine, head and neck, basic laparoscopy, complex laparoscopy, pediatrics, thoracic, and soft tissue/breast surgery in the 16-hour shift intern era, whereas there was no decrease in trauma, vascular, alimentary, endoscopy, liver, and pancreas cases. The study was published online on July 10, 2013, in JAMA Surgery.

“If the 16-hour shift were to be extended to all postgraduate year levels, one can anticipate that additional years of training will be needed to maintain the same operative volume,” concluded lead author Christian de Virgilio, MD, of Harbor-UCLA, and colleagues. “Given that the US healthcare system is already struggling to provide funding for graduate medical education and given the rising costs of medical education for students, such a prolongation of surgical residency training is unlikely to be viewed favorably.”

“Hopefully, as experience with the 16-hour rule is further expanded, we will be able to get the interns in the operating room more,” said Julie Ann Freischlag, MD, of the Johns Hopkins Medical Institutions (Baltimore, MD, USA), in an accompanying commentary. “There are three ways to do this; emphasize to the interns and the senior and chief residents that they need to get into the operating room at least three cases a week; use other healthcare deliverers to help with floor work, intensive care unit coverage, and clinics to allow the interns to get to those cases; and make sure the faculty understands the plan so they allow the intern to get to the operating room and that they allow the intern to actually do the operation.”

The Accreditation Council for Graduate Medical Education (ACGME; Chicago, IL, USA; www.acgme.org) mandated in 2003 that all residents could work no more than 80 hours per week. Spurred by concerns about the negative effects of longer shift lengths, the ACGME in 2011 further restricted shift lengths to 16 hours for postgraduate year-one residents and to 28 hours for other residents.

Related Links:
Harbor–UCLA Medical Center
University of Hawaii at Manoa