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more than purely a patient safety issue. The resident training system in Canada is
managed in a provincial fashion, and as of recently, there were no nationalized stan-
dards for resident work hours. In most provinces, there was a 24-hour maximum of
consecutive work hours with a time set aside for “handover” of patients. In Canada,
in-house call and home call are treated differently so that residents can work up to
and over 80 hours in a 7-day period depending on the breakdown of their call sched-
ule. In 2011, however, a Quebecois labor arbitrator successfully argued that a con-
secutive 24-hour shift was dangerous to the resident’s health and violated provincial
and national charters. This eventually resulted in a maximum work shift of 16 con-
secutive hours in Quebec. Currently, a task force is underway in formulating a uni-
versal consensus from national stakeholders [ 25 ].
Major changes in resident duty hours occurred shortly after the Libby Zion
case in Europe. Work hours are governed by the European Working Time
Directive (EWTD), whose focus is to protect the health and welfare of all work-
ers in the European Union (EU) nations. This directive has several elements,
including a 48-hour workweek, 11 hours of rest between 24-hour duty periods,
a minimum of one 24-hour period off every 7 days, and a maximum shift of
8 hours for “stressful” positions. These guidelines have been in place for all
workers but started to apply to resident physicians in 2008 [ 26 ]. The compliance
of the EU nations is highly variable. Denmark has been compliant and, in fact,
has an even lower 37-hour workweek. Sweden and Norway also have a 40 hours
workweek for resident physicians that has been in place since prior to EWTD
[ 27 , 28 ]. Finland and Germany are felt to be compliant although hard data is
lacking. The United Kingdom fully adopted the EWTD in 2009, but some
reports suggest that a significant proportion of junior doctors are exceeding the
maximum work hours [ 29 ]. It is unknown whether the other EU member nations
are compliant as no data exists. It is felt by authorities that they are probably
not, but some member nations recently became part of EU and may not have
been able to adopt the EWTD quickly. With the impending withdrawal of the
United Kingdom (and perhaps other nations) from the EU, it will be interesting
to see if EWTD restrictions are preserved or discarded in favor of new regula-
tions. In Australia and New Zealand, the training scheme has begun to fall into
line with the framework of the EWTD.
The severely limited work hours for non-US resident physicians have been
viewed with derision by medical educators in the United States as it seems that the
hours spent training seem impossibly limited. Many of these changes have occurred
in the recent past, and it may be too early to determine if these training paradigms
will continue to be successful in producing high-quality physicians in the surgical
specialties. It is perhaps sobering to remember that some of the working time limita-
tions also apply to the attending (consultant) physicians in these countries, and
therefore other physicians cannot compensate for diminished working hours. If
these countries can continue to produce competent and knowledgeable surgeons
under greater time constraints, perhaps we in the United States could adopt some of
the methods to increase the efficiency of our training programs.
D.J. Rea and M. Smith