18 4
cumulative pressure of these two scenarios may then change the demographics of
surgical practice for recent graduates, choosing to practice in larger groups with a
larger patient base to insulate them from working beyond 80 hours and from having
to tackle cases for which they feel unequipped. This may then further the shortage
of surgical providers in small communities in the United States. With all this in
mind, it will always be the goal of residency programs across the nation to train and
educate future surgeons to be competent surgeons that enjoy their career and pro-
vide high-quality care for coming generations.
The issue of duty hours in surgical education has been evolving for the last
40 years. We have seen the extremes of the past, where work hours were excessive
and detrimental to residents’ physical and emotional health. Unfortunately, the sur-
gical community maintained the status quo for many years – fueled by pride and
egotism – to the detriment of many trainees. Spurred on by the very public and
tragic death of Libby Zion, the issue of excessive duty hours and resident fatigue
was placed squarely in the crosshairs of public opinion; no longer could the medical
community sit silently by while this status quo was maintained. Pressures from
those inside and outside of the field of medicine led to restricted work hours man-
dated by the ACGME in 2003. This change then engendered a backlash of concern
that the surgical community might be sacrificing surgical competency for resident
well-being. Much of the data seemed to suggest that resident experience was
unchanged during this tumultuous time, however.
Further restrictions were put in place in 2011 based on data showing negative
patient-related consequences of even the 2003 ACGME restrictions. The continued
erosion of resident work hours prompted the design of randomized trial to deter-
mine if increasing flexibility of resident hours (without increasing the total hours
worked) would impact patient care. The landmark FIRST trial showed that when
resident work hours were liberalized, no difference in patient outcomes was noted.
Importantly, the residents themselves, though with less time for extracurricular
activities, felt more of a sense of patient engagement and greater satisfaction with
the educational process. This randomized data has now caused the ACGME to
reconsider some of the restrictions enacted in 2011. Where the future of duty-hour
restrictions is heading is unclear. Are we satisfied that the current system provides
that balance of producing highly skilled and competent surgeons who are also emo-
tionally and physically intact at the end of the process? Only careful study and time
will tell. As the surgical community goes forward in the future, the new standard of
high-quality randomized data will be our best guide at balancing patient and resi-
dent outcomes.
References
- Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview.
Acad Emerg Med. 2008;15(11):988–94. - Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance
in medicine and related domains. Acad Med. 2004;79(10 Suppl):S70–81. - Colvin G. Talent is overrated : what really separates world-class performers from everybody
else. New York: Portfolio; 2008.
D.J. Rea and M. Smith