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Commentary on: “Impact of the European Working Time Directive (EWTD) on the operative experience of surgical residents”
Commentary on: ‘‘Impact of the European Working Time Directive (EWTD) on the operative experience of surgical residents’’ Karen D. Horvath, MD, FACS and Carlos A. Pellegrini, MD, FACS, FRCSI (Hon), Seattle, WA
From the Department of Surgery, University of Washington, Seattle, WA
HOPMANS ET AL FROM THE NETHERLANDS present a retrospective analysis of resident operative data in a single residency program during the period 2005 2012 to answer the question: what impact has the European Working Time Directive (EWTD) had on the operative experience of surgical residents?1 The EWTD is akin to the Accreditation Council for Graduate Medical Education Duty Hours, which lays down requirements in relation to working hours, arrangements for night workers, rest periods, and annual leave. All European Union member states must adhere to the directive, with the aim of protecting doctors from the dangers of overwork and protecting patients from overtired doctors. In practical terms, the EWTD has progressively limited the average work week in the Netherlands from a maximum of 58 hours in 2004 to 56 hours in 2007, 52 hours in 2011, and full adoption of the 48-hour week in 2012. Moving from 58 to 48 hours per week, a 17% reduction in total work hours per resident, translates essentially into 1 less day per night of work per week. Although the study covers the period of transition, and does not actually reflect the effect of the implementation, the authors demonstrated they were able to maintain a robust operative experience and for this they must be heartily congratulated. At first glance, the case numbers appear quite high compared with US training programs. The
10.1016/j.surg.2014.09.025 Accepted for publication November 13, 2014. Reprint requests: Karen D. Horvath, MD, FACS, Professor of Surgery, Associate Chair for Education, Department of Surgery, Box 356410, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195. E-mail: [email protected]. Surgery 2015;157:642-4. 0039-6060/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2014.11.008
642 SURGERY
average operative experience per resident during the study period averaged 1,390 cases per graduating resident. In translating the 6-year training period in the Netherlands to the 5-year US system, the average of 1,390 cases during 6 years equates to roughly 232 cases per year, or 1,158 cases done in a 5-year US residency, which is not different from our training system. (Note: this translation is only for discussion purposes because case volume generally fluctuates greatly during each training year and doesn’t occur at a flat average.) The residents in this program, however, are doing roughly the same number of cases per year in a 48- to 58-hour work week that US residents do in an 80-hour work week. How can this be achieved? A closer examination of the EWTD shows several small differences that contribute to making these case numbers doable in a 48-hour work week. For example, the 48-hour week is averaged during a 6-month period (in the US, the 80 hours is averaged over 4 weeks). Equally relevant is the EWTD ‘‘minimum of 4 weeks’ paid vacation,’’ which is translated into 5.6 weeks paid vacation each year in the Netherlands and is included in the 6-month average. In the United States, the typical 3 weeks of vacation is excluded from the 80-hour average. There are also differences in rounding practices and daily ward care. For example, in The Netherlands, the nonsurgeon house-staff, which can be likened to our nondesignated preliminary residents in the United States, take care of the ward patients and rarely go to the operating room. In the United States, operative case requirements for our nondesignated preliminary residents are the same as for the categorical residents. Dutch surgery residents also have less experience in the intensive care unit (ICU) than US residents, spending 1 3month rotation during their residency in the ICU. This study was performed in a single residency program, which includes 1 university hospital and 5 district training community hospitals, typical for
Surgery Volume 157, Number 4
surgery residency programs in the Netherlands. Typically, Dutch surgery residents spend 2 years at the university hospital and 4 years in a district training hospital, where patient complexity is often lower, case length is shorter, and OR turn-around time is quicker, all contributing to greater case numbers. This is a potentially important lesson for us in the United States to learn in terms of use of academic and private institutions. In the Netherlands, all residents get the same experience of both types of training environments. This may help equalize both operative case numbers and duty hour issues over time, which may be different in different hospital environments. In the United States, resident training is far more skewed into one type of environment versus another, potentially creating greater disparities in work hours and operative case volume. Another element that may explain why these residents achieve high numbers despite the reduction in work hours to a mere 48 is compliance. The EWTD dictates that, ‘‘individual doctors can ‘opt out’ and work more than a 48hour week if they choose to do so.’’ How many of these residents took advantage of the EWTD option to ‘‘opt out?’’ This paper does not tell us, but in a 2014 report from the United Kingdom, it was reported that 70% of general surgery residents opted out.2 As these many factors are considered, the typical work day of a Dutch surgery resident starts to approximate that of a US resident, and the case numbers reported seem achievable. Although the approximate number of cases per year may be roughly comparable across the Atlantic, the final operative experience of a graduating resident going out into practice is considerably different. Dutch residents are graduating with an additional year of operative experience, or another 232 cases at minimum and probably much more. It is critical that operative case numbers be preserved, even more so in the 21st century. The graduate of just 20 years ago reported total case numbers of only open surgery. Now, this same case volume is divided between open, laparoscopic and robotic cases, further diluting the focused technical experience. Given this dilution problem, it gives credence to the recent concerns from graduates about not feeling comfortable with operative independence and begs the question: should we in the United States increase training from 5 to 6 years and have our graduates get another 232 cases under their belt like their colleagues across the Atlantic? We hasten to say that the answer is probably ‘‘no,’’ because we believe the confidence in their ability to operate
Horvath and Pellegrini 643
independently experienced by some graduates’ experience is more related to the lack of autonomy during residency training than to total number of cases. In contrast, all surgeons understand that training a surgeon is not just about case numbers and technical ability. Indeed, the RRC for surgery gives citations to US programs if the residents do more than 1,200 cases in 5 years because these high numbers are thought to indicate insufficient clinic, ward, and ICU experience. Nonoperating room experience is critical, and the authors make a statement that bears repeating at every opportunity, ‘‘The significance of merely operative competence is of limited importance for developing proficiency during surgical training.’’ Surgical training is about knowing when and when not to operate---a skill learned in the clinics. It’s also about knowing how to take care of patients in the perioperative period---a skill learned in the wards and ICU’s. In support of this fact, the authors quote the study comparing Canadian and Dutch surgeons demonstrating similar scores for technical skills and cognitive knowledge were similar but significantly different patient management skill scores. As the authors point out, adverse events are more likely to result from the latter, not the former. Case numbers alone are not the surrogate of a well-trained surgeon. There are a few items that the authors were unable to address, such as the 4-fold increase of graduating surgery residents from this program during the study period to provide for projected future needs and probably help meet the EWTD. If this same pattern was repeated in other residency programs in the Netherlands, are they creating a glut of surgeons? Are jobs available for these graduates? The efficient and very high quality of care environment of the Netherlands is enviable and must draw us to reach for greater levels. This study is provocative and generates many more questions than it answers. Are we really doing this surgery resident training in the best way in the United States? So often the answer lies not in the radical extremes, but in moderation in the middle. It will help surgeons to define where the far reaches of extremism are, so that modulation also can be defined. Time for sleep, rest, family, self, and fun is needed to be a good human as much as to be a good surgeon. But where does this needle lie? Certainly the 116-hour work week was too far in one direction, but we offer that 48 hours might be too far in the other direction. Whether the answer lies at 58 hours or 80 hours per week,
644 Horvath and Pellegrini
it’s essential that the full picture is evaluated as a whole. Surgery training is different from nonsurgery specialties because technical proficiency is required along with patient evaluation and management skills. It’s critical that when we look at our colleagues across the Atlantic, that we look at the full picture and not just the independent elements.
Surgery April 2015
REFERENCES 1. Hopmans CJ, den Hoed PT, van der Laan L, et al. Impact of the European Working Time Directive (EWTD) on the operative experience of surgical residents. Surgery 2015;157:634-41. 2. The Implementation of the Working Time Directive, and its Impact on the NHS and Health Professionals Report of the Independent Working Time Regulations Taskforce to the Department of Health. Available from: http://www.rcseng. ac.uk/policy/documents/wtd-taskforce-report-2014.
From the Department of Surgery, University of Washington, Seattle, WA
HOPMANS ET AL FROM THE NETHERLANDS present a retrospective analysis of resident operative data in a single residency program during the period 2005 2012 to answer the question: what impact has the European Working Time Directive (EWTD) had on the operative experience of surgical residents?1 The EWTD is akin to the Accreditation Council for Graduate Medical Education Duty Hours, which lays down requirements in relation to working hours, arrangements for night workers, rest periods, and annual leave. All European Union member states must adhere to the directive, with the aim of protecting doctors from the dangers of overwork and protecting patients from overtired doctors. In practical terms, the EWTD has progressively limited the average work week in the Netherlands from a maximum of 58 hours in 2004 to 56 hours in 2007, 52 hours in 2011, and full adoption of the 48-hour week in 2012. Moving from 58 to 48 hours per week, a 17% reduction in total work hours per resident, translates essentially into 1 less day per night of work per week. Although the study covers the period of transition, and does not actually reflect the effect of the implementation, the authors demonstrated they were able to maintain a robust operative experience and for this they must be heartily congratulated. At first glance, the case numbers appear quite high compared with US training programs. The
10.1016/j.surg.2014.09.025 Accepted for publication November 13, 2014. Reprint requests: Karen D. Horvath, MD, FACS, Professor of Surgery, Associate Chair for Education, Department of Surgery, Box 356410, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195. E-mail: [email protected]. Surgery 2015;157:642-4. 0039-6060/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2014.11.008
642 SURGERY
average operative experience per resident during the study period averaged 1,390 cases per graduating resident. In translating the 6-year training period in the Netherlands to the 5-year US system, the average of 1,390 cases during 6 years equates to roughly 232 cases per year, or 1,158 cases done in a 5-year US residency, which is not different from our training system. (Note: this translation is only for discussion purposes because case volume generally fluctuates greatly during each training year and doesn’t occur at a flat average.) The residents in this program, however, are doing roughly the same number of cases per year in a 48- to 58-hour work week that US residents do in an 80-hour work week. How can this be achieved? A closer examination of the EWTD shows several small differences that contribute to making these case numbers doable in a 48-hour work week. For example, the 48-hour week is averaged during a 6-month period (in the US, the 80 hours is averaged over 4 weeks). Equally relevant is the EWTD ‘‘minimum of 4 weeks’ paid vacation,’’ which is translated into 5.6 weeks paid vacation each year in the Netherlands and is included in the 6-month average. In the United States, the typical 3 weeks of vacation is excluded from the 80-hour average. There are also differences in rounding practices and daily ward care. For example, in The Netherlands, the nonsurgeon house-staff, which can be likened to our nondesignated preliminary residents in the United States, take care of the ward patients and rarely go to the operating room. In the United States, operative case requirements for our nondesignated preliminary residents are the same as for the categorical residents. Dutch surgery residents also have less experience in the intensive care unit (ICU) than US residents, spending 1 3month rotation during their residency in the ICU. This study was performed in a single residency program, which includes 1 university hospital and 5 district training community hospitals, typical for
Surgery Volume 157, Number 4
surgery residency programs in the Netherlands. Typically, Dutch surgery residents spend 2 years at the university hospital and 4 years in a district training hospital, where patient complexity is often lower, case length is shorter, and OR turn-around time is quicker, all contributing to greater case numbers. This is a potentially important lesson for us in the United States to learn in terms of use of academic and private institutions. In the Netherlands, all residents get the same experience of both types of training environments. This may help equalize both operative case numbers and duty hour issues over time, which may be different in different hospital environments. In the United States, resident training is far more skewed into one type of environment versus another, potentially creating greater disparities in work hours and operative case volume. Another element that may explain why these residents achieve high numbers despite the reduction in work hours to a mere 48 is compliance. The EWTD dictates that, ‘‘individual doctors can ‘opt out’ and work more than a 48hour week if they choose to do so.’’ How many of these residents took advantage of the EWTD option to ‘‘opt out?’’ This paper does not tell us, but in a 2014 report from the United Kingdom, it was reported that 70% of general surgery residents opted out.2 As these many factors are considered, the typical work day of a Dutch surgery resident starts to approximate that of a US resident, and the case numbers reported seem achievable. Although the approximate number of cases per year may be roughly comparable across the Atlantic, the final operative experience of a graduating resident going out into practice is considerably different. Dutch residents are graduating with an additional year of operative experience, or another 232 cases at minimum and probably much more. It is critical that operative case numbers be preserved, even more so in the 21st century. The graduate of just 20 years ago reported total case numbers of only open surgery. Now, this same case volume is divided between open, laparoscopic and robotic cases, further diluting the focused technical experience. Given this dilution problem, it gives credence to the recent concerns from graduates about not feeling comfortable with operative independence and begs the question: should we in the United States increase training from 5 to 6 years and have our graduates get another 232 cases under their belt like their colleagues across the Atlantic? We hasten to say that the answer is probably ‘‘no,’’ because we believe the confidence in their ability to operate
Horvath and Pellegrini 643
independently experienced by some graduates’ experience is more related to the lack of autonomy during residency training than to total number of cases. In contrast, all surgeons understand that training a surgeon is not just about case numbers and technical ability. Indeed, the RRC for surgery gives citations to US programs if the residents do more than 1,200 cases in 5 years because these high numbers are thought to indicate insufficient clinic, ward, and ICU experience. Nonoperating room experience is critical, and the authors make a statement that bears repeating at every opportunity, ‘‘The significance of merely operative competence is of limited importance for developing proficiency during surgical training.’’ Surgical training is about knowing when and when not to operate---a skill learned in the clinics. It’s also about knowing how to take care of patients in the perioperative period---a skill learned in the wards and ICU’s. In support of this fact, the authors quote the study comparing Canadian and Dutch surgeons demonstrating similar scores for technical skills and cognitive knowledge were similar but significantly different patient management skill scores. As the authors point out, adverse events are more likely to result from the latter, not the former. Case numbers alone are not the surrogate of a well-trained surgeon. There are a few items that the authors were unable to address, such as the 4-fold increase of graduating surgery residents from this program during the study period to provide for projected future needs and probably help meet the EWTD. If this same pattern was repeated in other residency programs in the Netherlands, are they creating a glut of surgeons? Are jobs available for these graduates? The efficient and very high quality of care environment of the Netherlands is enviable and must draw us to reach for greater levels. This study is provocative and generates many more questions than it answers. Are we really doing this surgery resident training in the best way in the United States? So often the answer lies not in the radical extremes, but in moderation in the middle. It will help surgeons to define where the far reaches of extremism are, so that modulation also can be defined. Time for sleep, rest, family, self, and fun is needed to be a good human as much as to be a good surgeon. But where does this needle lie? Certainly the 116-hour work week was too far in one direction, but we offer that 48 hours might be too far in the other direction. Whether the answer lies at 58 hours or 80 hours per week,
644 Horvath and Pellegrini
it’s essential that the full picture is evaluated as a whole. Surgery training is different from nonsurgery specialties because technical proficiency is required along with patient evaluation and management skills. It’s critical that when we look at our colleagues across the Atlantic, that we look at the full picture and not just the independent elements.
Surgery April 2015
REFERENCES 1. Hopmans CJ, den Hoed PT, van der Laan L, et al. Impact of the European Working Time Directive (EWTD) on the operative experience of surgical residents. Surgery 2015;157:634-41. 2. The Implementation of the Working Time Directive, and its Impact on the NHS and Health Professionals Report of the Independent Working Time Regulations Taskforce to the Department of Health. Available from: http://www.rcseng. ac.uk/policy/documents/wtd-taskforce-report-2014.