Surgeons Decry Latest Duty-Hour Restrictions

SAN FRANCISCO -- The American College of Surgeons could consider taking over resident training from the Accreditation Council of Graduate Medical Education to avoid the council's latest duty-hour restrictions, which went into effect in July.

In considering strategies to address the unwelcome restrictions, "we haven't taken anything off the table," said Dr. L.D. Britt, immediate past president of the American College of Surgeons (ACS) and chair of the ACS Task Force on Resident Duty Hours. "We shouldn't allow any entity to destroy our training programs."

At least one College official later said the College has no plans to take over accreditation of residency programs, but the mere mention of this possibility as an option drew cheers at an emotional, standing-room-only session on resident duty hours during the annual Clinical Congress of the American College of Surgeons.

Dr. Britt and a panel of ACS leaders described their efforts thus far to modify the new duty-hour requirements before and after they went into effect. The session was the first time surgeons had gathered in large numbers since the new rules went into effect, and many of them vented their frustrations.

They objected most to the 16-hours/day limit on first-year residents. "The 16-hour day is an enemy to education," said Dr. Britt, an ACS Fellow and Brickhouse Professor of Surgery and Chairman at Eastern Virginia Medical School, Norfolk.

Limitations on the work hours of surgical trainees in England, Switzerland, and other European countries have been "devastating" to the quality of education there, he said. "Why aren't they looking at the international experience?" Dr. Britt asked in a lengthy discussion session after the formal presentations.

He and others emphasized that there are no data showing that reduced hours lead to better patient outcomes. On the contrary, the limits could hurt patients by increasing the risk for errors because the new schedule leads to an increased number of patient hand-offs and gives residents less experience, they suggested.

Dr. Ajit K. Sachdeva, an ACS Fellow, director of the ACS Division of Education, and moderator of the session, said in a phone interview afterward that there has been "a lot of chatter" on ACS listservs about the duty-hour restrictions, but the ACS "has no plans" to take over residency program accreditations.

"There's a prevailing sense in the surgical community that the 16 hours a day is not going to be good for surgical training and actually will do harm, because you will have less well-trained people in the future," said Dr. Sachdeva, adjunct professor of surgery at Northwestern University, Chicago. The ACS will continue to try to get the Accreditation Council of Graduate Medical Education (ACGME) to expand the daily 16-hour limit for first-year residents and to keep the 80-hour weekly limit from shrinking.

Under the 2011 regulations, residents must break the rules to get needed experience in continuity of care, said Dr. Thomas V. Whalen, an ACS Fellow and chief medical officer, department of surgery, Lehigh Valley Health Network, Allentown, Pa.

Dr. Whalen, who served on the ACGME task force that reviewed and revised the 2003 regulations, said that pressure for tighter limits on resident duty hours came largely from sleep scientists such as Dr. Charles A. Czeisler, professor and director of the division of sleep medicine, Harvard University, and chief of the division of sleep medicine at Brigham and Women's Hospital, Boston.

Dr. Czeisler said in an interview that he is an advocate of patient safety and evidence-based medicine. "In fact, this year is the 40th anniversary of the first study demonstrating that extended-duration shifts double the rate of errors that interns make when detecting cardiac arrhythmias," he said. Since then, his research has shown that work shifts longer than 24 hours lead to a 460% increase in serious diagnostic mistakes made by resident physicians caring for critically ill patients in the ICU, a 73% increase in the risk of percutaneous injuries, and a 168% increase in the odds of a resident being in a motor vehicle crash while driving home, among other adverse consequences.

An Institute of Medicine (IOM) consensus statement in December 2008 recommended, among other things, that 5 hours of sleep be allowed after any shift longer than 16 hours, and that this sleep time be counted toward the 80-hour/week limit, averaged over 4 weeks.

The ACS published a detailed response to the IOM report, arguing that the 16 hours/day limit "is entirely unworkable in the surgical environment" (Surgery 2009;146:398-409).

The ACGME rules don't go as far as the IOM recommendations because the ACGME applied the 16 hours/day limit only to interns and not to other residents, Dr. Czeisler has noted in previously published statements.