183negatively affect patient care and the wellness of residents. It would seem that the
current policy of the ACGME is to look for high-quality data and make incremental
adjustments in reforming the duty-hours.
In order to combat the perceived uneasiness of some surgical chief resident to
directly enter practice, the American College of Surgeons has proposed the use of a
“transition to practice” fellowship [ 62 – 65 ]. These are fellowships that allow a
“pseudo-autonomy” of the fellow to operate under the mentorship of a more senior
surgeon. Some of these fellowships include performing cases in other surgical dis-
ciplines such as urology, neurosurgery, plastic surgery, and orthopedics. Ironically,
for many general surgery programs, these rotations were once components of train-
ing but have been diminished or removed due to the work-hour restrictions. Some
have argued for the advantages of this type of program, but is this really different
than an extra year of residency? We can foresee the utility of these types of pro-
grams for residents who later in their training decide they would like to work in an
environment where they would be a “proceduralist” who needs basic skills in these
other surgical disciplines (e.g., a rural surgery practice or as a medical missionary).
Perhaps we need to consider the types of residents or programs whose graduates
feel they need this type of extra attention and more closely examine why their previ-
ous system did not meet their needs. Perhaps this also would suggest that PGY-5
level residents should be given considerably more autonomy and even less regula-
tions on their hours to facilitate a smooth transition to practice. These programs are
currently not widespread, but we should watch carefully how these are used.
Certainly, the fellows in these programs could be seen as cheap (but skilled) labor
as opposed to continuing learners.
The long-term effects of residents having trained in the current duty-hour restric-
tions are something that will not be known for several years to decades. Certainly
several scenarios come to mind. Will limitations of duty hours now cause increased
job dissatisfaction and burnout among future surgeons when their jobs demand
work hours that exceed 80 hours per week? If more senior surgeons have a distrust
of the abilities of their newly graduated colleagues, how will that manifest as for the
employability of the future generations of surgeons. The issue of burnout has
become front and center in the medical community. Although probably not a new
phenomenon, burnout has been invoked as a major contributor to physicians leaving
medicine. Current data suggest that general surgery and surgical subspecialties are
affected by burnout at a high rate than many other specialties [ 66 – 70 ]. Can the cur-
rent duty-hour restrictions contribute to even high rates of burnout in the future?
One could argue that training in an 80 hours per week system and then graduating
to a surgical practice where one is expected to work greater than 80 hours per week
would create added stress and job dissatisfaction, thereby leading to burnout. This
situation could certainly be magnified by choosing to practice in a smaller commu-
nity where there is less support, and the local surgeon is expected to provide care
ceaselessly. If we are also training surgeons with less clinical experience during
their residency, we could also imagine that our recent graduates may be less well
equipped to handle difficult surgical cases, thereby increasing their personal dis-
satisfaction with their job, leading to increased rates of burnout as well. The
9 Resident Duty Hours in Surgical Education