- Email: [email protected]
The challenge of reduced trainee hours in Australia on surgical teachers
The challenge of reduced trainee hours in Australia on surgical teachers Guy J. Maddern, MD, FRACS, Adelaide, Australia
From the Department of Surgery, University of Adelaide, Adelaide, Australia
CHANGE IN WORKING HOURS THE AUSTRALIAN HEALTH SYSTEM has approximately 60% of the population receiving its healthcare in public hospitals under a universal health insurance system and 40% receiving care through a private hospital health system supported in part by the public purse. Teaching of surgical trainees occurs predominantly within the public hospital system and comprises a general intern year followed by 2 basic surgical training years. This is followed by a series of assessments that leads to acceptance into the advanced surgical program that, depending on the subspecialty pursued, currently takes between 5 and 6 years to complete. Before the completion of training, a final examination is taken that, when successfully passed, leads to the award of the Fellowship of the Royal Australasian College of Surgeons. On completion of training, surgical trainees are considered to be suitable to enter surgical practice anywhere in Australia and New Zealand. Frequently, an additional year or two of senior registrar training is pursued to develop subspecialty interests. This system is managed with respect to review of standards and accreditation by the Royal Australasian College of Surgeons, which sets the examinations, conducts them, and defines what a training post must include. However, the employer of these trainee surgeons is the hospital authority. Increasing pressures on the availability of health funds within Australia has led many hospitals and health authorities to demand increased service commitment from their staff. This in turn causes difficulty in providing the same level of in-service teaching and training that had previously been available. The situation has been complicated further by the various Accepted for publication March 7, 2003. Surgery 2003;134:23-6. Reprint Requests: Guy J. Maddern, MD, Department of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Woodville Road, Woodville S.A. 5011, Australia. © 2003 Mosby, Inc. All rights reserved. 0039-6060/2003/$30.00 + 0 doi:10:1067/msy.2003.182
trainee hospital doctors’ industrial organizations seeking improved conditions and rates of pay for their members. Similar to North America, each of the six States and two Territories within Australia have autonomous health authorities that determine the awards and conditions of their medical staff. The fine detail within each state is different, and exceptional circumstances can be argued for isolated or poorly served regions in the terms and conditions under which doctors in surgical training can be employed. Nonetheless, over the last decade, there has been a continuing push to reduce the number of hours being worked by junior medical staff. The days of 36hour shifts are now largely outlawed and have been replaced by maximum working periods of 13 to 14 hours with mandated rest periods before the next period of work can commence. This has led to more civilized and rational hours but has carried with it the significant problems of staffing hospitals across the evenings, providing continuity of care for the patients, accommodating the demand for educational aspects of surgical training, and providing sufficient clinical experience during the course of a surgical apprenticeship. The sanctions that can be directed toward hospitals or individuals who fail to conform to these reduced working hours are considerable. The medico-legal risk that a hospital exposes itself to if it does not follow the “safe working hours” approach has been, to date, untested, but is much feared. Financially there are significant penalties if one breaches the mandated working hour arrangements. Penalty rates apply at a punitive level to the hospital to compensate the individual who has worked more than their recommended hours. In fact, within South Australia, if an individual does not have 30 minutes for lunch, he is paid at time-and-a-half for every hour worked after the foregone lunch break! Many of the senior surgical staff have found these changes difficult to comprehend, particularly when they consider the nature of their training, often only 10 or 15 years earlier. It is probably true that many of the resident staff now believe and expect that this is an appropriate way to be employed by a health SURGERY 23
24 Maddern
authority. They have used this opportunity to enhance their lifestyles, enabling them to spend more time with their families, pursue other interests, or even reduce their golf handicaps. The changes associated with the reduction in resident hours, the punctuation of these periods by mandated rest, and the need to have other staff take care of individual patients has led to great change in the way in which public hospitals work to provide a safe and responsive environment to patients. The impact of these changes varies around the country, but the general effect has been to see a more consultant-led supervision of care and less responsibility falling to the registrars to maintain ongoing continuity. To deal with some of this challenge, units that had previously had a single registrar working for a group of consultants now would typically have two or more registrars being responsible for the care of the surgical unit’s patients. In this way, it is possible to provide adequate time off on weekends and overnight, and keep the number of hours down to what is financially, medically, and legally acceptable. This, however, has carried with it significant impact for the consultant staff, the surgical teachers. Within Australia, most public hospitals have very few full-time surgical staff. The consultant staff is usually made up of visiting medical officers who would typically give between 2 and 5 half-days a week to the care of public hospital patients. The remainder of their time would be spent working within the private hospital sector performing more richly remunerated services. The services that the consultant staff provides to the public hospital is relatively poorly paid but valued for its opportunity to teach junior staff and maintain a peer-reviewed and contemporary practice in an environment geared to the management of complex surgical problems. For this reason, despite the relatively poor rates of pay for visiting medical officers compared with the financial rewards in private practice, positions within the public hospital sector are keenly sought. However, as the pressure on consultants increases—especially if they only provide 3 or 4 half-days a week to the public hospital sector and if registrar staff are unable to give continuity of care—there is a real challenge to have structures in place that keep errors of patient management from occurring. CHALLENGES OF REDUCED WORKING HOURS Teaching. Because of the reduction in their working hours, teaching of trainee surgical staff is becoming much more difficult. This means that more surgical trainees need to be working within a given surgical unit, which has led to increased demands on individual consultants who must now
Surgery July 2003
teach 2 or 3 times the number of trainees as compared to previous years. This has not necessarily led to a diminution in teaching and, with additional individuals requiring tuition, there is a positive incentive to prepare more fully for the group passing through the unit as the efforts are appreciated 2- or 3-fold more than in the past. Teaching is usually done during daylight hours. However, the hospital system is reluctant to provide paid time for this teaching. This has meant that, unlike in the past when the teaching was part of the surgical job, it must now be structured outside working hours, for example, on Saturday mornings or at the end of the paid working day. Surgical trainees, however, still feel this is their right, and it will take years before they realize how privileged they are to have unpaid tuition provided by experienced senior surgical colleagues unsupported by the public hospital system and performed in an entirely honorary capacity. Alternatively, they may be required to “buy” this tuition from the surgical teachers. This has already begun within the basic surgical training period in which a number of training modules need to be completed. These educational modules are paid for by the trainees and usually take the form of 2- or 3day courses that run over weekends. Rostering. Any surgical director in Australia has developed significant sympathy for anyone charged with the responsibilities of organizing rail or airline timetables. The need to accommodate leave, illness, and study time as well as conform to the industrial arrangements concerning employment of individual trainee medical officers makes developing rosters for most surgical units a nightmare. This is because the hours dictated by the industrial awards within many States of Australia were devised by tribunals with little regard for the day-to-day functioning of hospitals and their need to provide 24-hour coverage for the patients. Nonetheless, rostering has been achieved to meet most of the rules and regulations, and has led to an increased number of trainees being accommodated within the system to provide appropriate junior staffing within the public hospital sector. Patient care. At this stage, it is unclear whether patient care has suffered as a result of these substantial changes in surgical staffing arrangements. Poor outcomes have occurred, but whether these would truly have been prevented by reverting to the old days of exhausted trainees, barely able to stay awake at the end of a 36-hour shift and caring for too many patients, is probably questionable. On the whole, patient care has probably been protected by an increasing involvement of the consultant medical staff in the close surveillance of patients under their
Surgery Volume 134, Number 1
direct management. It has also led to a small but increasing number of full-time staff specialists being appointed within major public hospitals to ensure that day-to-day decisions can be made in a timely and responsible fashion. It may even be that the change in junior staffing hours has led to improved patient care as more senior members of staff have become involved directly in the decision-making that had been left to more junior members of staff. Surgical experience. Despite all these changes, the actual case load passing through the public hospital system has not altered substantially. At the same time, the number of individuals providing surgical care within the hospital system has increased. This has led to considerable competition for the surgical cases available to provide an appropriate surgical experience during the course of training. The lack of long hours through the night to cover the emergency load has probably had very little impact on surgical experience for many surgical trainees. It would seem doubtful, after the first dozen or so perianal abscesses or lacerated scalps, that much could be learned from the next 50 or 60 such cases. Most major surgery, and certainly complex surgical problems, are managed during daylight hours, and these cases can all be presented to the junior staff working within the hospital. Surgery around the world has yet to determine the minimum number of cases one must handle to become a competent surgeon.1 Before presenting for the Part II Australian Fellowship in general surgery, trainees must have been involved with at least 500 major cases and 100 endoscopies and 50 colonoscopies.2 Surgical competence is probably a very variable factor, depending more on the individual than any mandated number that can be established. Nonetheless, because competition for exposure to a range of operative situations has increased, it has become essential that all cases performed within the public hospital system be offered to junior staff under direct consultant supervision. When this occurs, there is a slowing down in the number of patients who can be treated, with associated impact on the case mix volume passing through institutions. This cost of training is an area that is now beginning to challenge hospital administrators and health authorities as they attempt to understand the real costs associated with having trainee doctors rather than experienced consultants performing surgery within their facility. From a purely cost-benefit point of view, it would be better that all cases were performed by consultants with no junior staff involvement. However, such an approach would destroy surgical training programs and lead to a shortage of sur-
Maddern 25
geons, eventually increasing costs to attract them to health facilities. The analysis, though, is complex and to date has not been successfully conducted within Australia. One area that remains largely untapped but may also become increasingly valuable in providing sufficient surgical experience to trainee surgical staff is the 40% of patients who are privately insured and not usually using the public hospital system. One challenge that remains is to expose trainee surgeons to the interesting and unusual cases being performed in the private health sector to compensate for the potential loss of such cases to trainees within the public hospitals. This area is currently being addressed in some centers and, once an appropriate model has been developed, it will have to be considered for wider introduction. As the number of cases that individual trainees actually handle is reduced, there is a real risk that the length of surgical training will have to be extended. This may not occur formally; however, it will lead to individuals seeking post-fellowship opportunities to gain sufficient clinical experience before becoming consultant surgical staff. These post-fellowship trainees then push pre-fellowship candidates further back in their quest for surgical experience. In Australia the implication is that typically, an individual can finish his or her medical school education by the age of 23 or 24 (unless he pursues a postgraduate training course, which are increasing in number within Australia). He or she would then complete internship and basic surgical training by the age of 27 and surgical training would be concluded, if uninterrupted, by the age of 32 or so. If an additional 2 or 3 years of training, or even more, are required, the individual may well be in his middle to late 30s before he has acquired sufficient experience to practice independently. This extraordinarily long training is a great disincentive to many individuals, particularly women, who see it as incompatible with having a family and still finishing training in time to have a worthwhile practicing life ahead. Because of this prolonged period, when surgery is compared with radiology, anesthesia, and general practice, for example, it could be seen as a less desirable option, given the more focused and rapidly concluded training options available in these other specialties. HOW TO MANAGE THE CHALLENGE Is it possible to imagine a hospital structure that can accommodate these reduced working hours, provide excellent teaching, roster patient care, sufficient number of cases, and not lengthen the training? From the outset, it is important that hospitals establish a well-organized preadmission system that
26 Maddern
enables junior staff to attend a group of patients being prepared for their elective admissions for surgery. This enables clear surgical protocols to be developed and implemented, and gives surgical trainees a good opportunity to appreciate the issues involved in surgical preparation, consent, and discharge planning. This approach also helps develop an efficient use of residents’ time to maximize the number of patients seen. Once a patient has been admitted into the hospital system, it is essential that standardized handovers and clear delineation of responsibilities be established for the resident staff. Consultant supervision is essential for this to occur and anything less than complete and relevant handovers cannot be tolerated within the current hospital system. The benefits of such an approach have been to implement an almost ongoing peer review at a junior staff level. This has meant that individual registrars have made sure they have fully acquainted themselves with the details of their patients before handing them over to the surgical colleague. The surgical colleague has the opportunity to review what is being undertaken with the patient and suggest additional investigations, diagnoses, or treatment strategies. It is very difficult in a well-structured handover situation to have ongoing perpetuation of errors unless false information has been unknowingly acquired. Indeed, well-designed handover of patients is a concept that could be extended to consultant staff. The whole concept of individual surgeons providing “continuity of care” may be outdated. Continuity of care will need to be provided by the unit or team, not the individual consultant surgeon, resident, or registrar. It is only through team care that patient safety can be guaranteed under the restrictive working hour trends. However, to provide continuous feedback on patient care and, therefore, a first-rate educational environment, there is an increasing need to have at least one full-time consultant functioning within each surgical unit. This individual must have oversight of all patients being treated by the unit, to the extent that a significant question regarding the care being delivered by one of the visiting medical staff be brought to that individual’s attention by the full-time consultant. Such an environment can lead to resentment and hostility; however, when developed as an educational and peer-review system, it can be seen as a positive interaction. Much of the care provided to surgical patients in the operating room is from surgical trainees; wards, however, are greatly assisted by the placement of interns. Interns are becoming a rare commodity, and the need for other forms of clinical support, such as nurse practitioners, is more evident. Many of
Surgery July 2003
the functions traditionally allocated to intern can be performed better by nurse practitioners familiar with the unit. This would free the interns up for a more general educational experience rather than one dominated by learning idiosyncratic unit policies and performing repetitive clerical functions. The need to provide good quality care for patients means that there is a greater need for more experienced junior medical staff than just the interns. Most public hospital surgical wards now care for a larger number of sicker patients than in the past. This has occurred because of the rapid escalation of ambulant surgery within many parts of surgical practice. Depending on the unit and the hospital, ambulant surgery is provided for 50% to 70% of all patients treated within the public hospital sector. These patients attend during daylight hours and, if their surgery is consultant-supervised, provide an excellent opportunity for staff training if the logistic issues that make junior staff available for these cases can be overcome.3 CONCLUSION The reduction in work hours within the Australian health scene has arrived in a fragmented and poorly coordinated fashion, but its effect has been considerable. The result has not necessarily led to worse health care. Indeed, it may be that because of the clear challenges it provides to surgical teachers within the public hospital sector, better programs will be devised. It is possible that the teaching component of surgical training will be more highly valued as time goes on. Patient care may be enhanced by more peer review and senior clinician involvement; rostering arrangements will lead to less stressed and potentially happier surgical residents; and a greater priority will be placed on using all patients passing through the system as potential teaching opportunities. There will never be a return to the number of hours worked by junior staff in the past, and it is reasonable to predict that with the change in trainee demographics (increasing age and more women), working hours will continue to decrease. The next generation of specialists will have completely different work expectations, and innovative training programs will be needed to meet the challenge. REFERENCES 1. Harder F. “I would like to be a surgeon, but …”. Ann Surg 2002; 236(6):699-702. 2. The Royal Australasian College of Surgeons. The surgical training programme in general surgery —regulations. Available from: http://www.racs.edu.au/edu/training/ reg.html 3. Bruening M, Maddern GJ. Undergraduate surgical education in an ambulatory surgery setting. Amb Surg 2001; 9:155-8.
From the Department of Surgery, University of Adelaide, Adelaide, Australia
CHANGE IN WORKING HOURS THE AUSTRALIAN HEALTH SYSTEM has approximately 60% of the population receiving its healthcare in public hospitals under a universal health insurance system and 40% receiving care through a private hospital health system supported in part by the public purse. Teaching of surgical trainees occurs predominantly within the public hospital system and comprises a general intern year followed by 2 basic surgical training years. This is followed by a series of assessments that leads to acceptance into the advanced surgical program that, depending on the subspecialty pursued, currently takes between 5 and 6 years to complete. Before the completion of training, a final examination is taken that, when successfully passed, leads to the award of the Fellowship of the Royal Australasian College of Surgeons. On completion of training, surgical trainees are considered to be suitable to enter surgical practice anywhere in Australia and New Zealand. Frequently, an additional year or two of senior registrar training is pursued to develop subspecialty interests. This system is managed with respect to review of standards and accreditation by the Royal Australasian College of Surgeons, which sets the examinations, conducts them, and defines what a training post must include. However, the employer of these trainee surgeons is the hospital authority. Increasing pressures on the availability of health funds within Australia has led many hospitals and health authorities to demand increased service commitment from their staff. This in turn causes difficulty in providing the same level of in-service teaching and training that had previously been available. The situation has been complicated further by the various Accepted for publication March 7, 2003. Surgery 2003;134:23-6. Reprint Requests: Guy J. Maddern, MD, Department of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Woodville Road, Woodville S.A. 5011, Australia. © 2003 Mosby, Inc. All rights reserved. 0039-6060/2003/$30.00 + 0 doi:10:1067/msy.2003.182
trainee hospital doctors’ industrial organizations seeking improved conditions and rates of pay for their members. Similar to North America, each of the six States and two Territories within Australia have autonomous health authorities that determine the awards and conditions of their medical staff. The fine detail within each state is different, and exceptional circumstances can be argued for isolated or poorly served regions in the terms and conditions under which doctors in surgical training can be employed. Nonetheless, over the last decade, there has been a continuing push to reduce the number of hours being worked by junior medical staff. The days of 36hour shifts are now largely outlawed and have been replaced by maximum working periods of 13 to 14 hours with mandated rest periods before the next period of work can commence. This has led to more civilized and rational hours but has carried with it the significant problems of staffing hospitals across the evenings, providing continuity of care for the patients, accommodating the demand for educational aspects of surgical training, and providing sufficient clinical experience during the course of a surgical apprenticeship. The sanctions that can be directed toward hospitals or individuals who fail to conform to these reduced working hours are considerable. The medico-legal risk that a hospital exposes itself to if it does not follow the “safe working hours” approach has been, to date, untested, but is much feared. Financially there are significant penalties if one breaches the mandated working hour arrangements. Penalty rates apply at a punitive level to the hospital to compensate the individual who has worked more than their recommended hours. In fact, within South Australia, if an individual does not have 30 minutes for lunch, he is paid at time-and-a-half for every hour worked after the foregone lunch break! Many of the senior surgical staff have found these changes difficult to comprehend, particularly when they consider the nature of their training, often only 10 or 15 years earlier. It is probably true that many of the resident staff now believe and expect that this is an appropriate way to be employed by a health SURGERY 23
24 Maddern
authority. They have used this opportunity to enhance their lifestyles, enabling them to spend more time with their families, pursue other interests, or even reduce their golf handicaps. The changes associated with the reduction in resident hours, the punctuation of these periods by mandated rest, and the need to have other staff take care of individual patients has led to great change in the way in which public hospitals work to provide a safe and responsive environment to patients. The impact of these changes varies around the country, but the general effect has been to see a more consultant-led supervision of care and less responsibility falling to the registrars to maintain ongoing continuity. To deal with some of this challenge, units that had previously had a single registrar working for a group of consultants now would typically have two or more registrars being responsible for the care of the surgical unit’s patients. In this way, it is possible to provide adequate time off on weekends and overnight, and keep the number of hours down to what is financially, medically, and legally acceptable. This, however, has carried with it significant impact for the consultant staff, the surgical teachers. Within Australia, most public hospitals have very few full-time surgical staff. The consultant staff is usually made up of visiting medical officers who would typically give between 2 and 5 half-days a week to the care of public hospital patients. The remainder of their time would be spent working within the private hospital sector performing more richly remunerated services. The services that the consultant staff provides to the public hospital is relatively poorly paid but valued for its opportunity to teach junior staff and maintain a peer-reviewed and contemporary practice in an environment geared to the management of complex surgical problems. For this reason, despite the relatively poor rates of pay for visiting medical officers compared with the financial rewards in private practice, positions within the public hospital sector are keenly sought. However, as the pressure on consultants increases—especially if they only provide 3 or 4 half-days a week to the public hospital sector and if registrar staff are unable to give continuity of care—there is a real challenge to have structures in place that keep errors of patient management from occurring. CHALLENGES OF REDUCED WORKING HOURS Teaching. Because of the reduction in their working hours, teaching of trainee surgical staff is becoming much more difficult. This means that more surgical trainees need to be working within a given surgical unit, which has led to increased demands on individual consultants who must now
Surgery July 2003
teach 2 or 3 times the number of trainees as compared to previous years. This has not necessarily led to a diminution in teaching and, with additional individuals requiring tuition, there is a positive incentive to prepare more fully for the group passing through the unit as the efforts are appreciated 2- or 3-fold more than in the past. Teaching is usually done during daylight hours. However, the hospital system is reluctant to provide paid time for this teaching. This has meant that, unlike in the past when the teaching was part of the surgical job, it must now be structured outside working hours, for example, on Saturday mornings or at the end of the paid working day. Surgical trainees, however, still feel this is their right, and it will take years before they realize how privileged they are to have unpaid tuition provided by experienced senior surgical colleagues unsupported by the public hospital system and performed in an entirely honorary capacity. Alternatively, they may be required to “buy” this tuition from the surgical teachers. This has already begun within the basic surgical training period in which a number of training modules need to be completed. These educational modules are paid for by the trainees and usually take the form of 2- or 3day courses that run over weekends. Rostering. Any surgical director in Australia has developed significant sympathy for anyone charged with the responsibilities of organizing rail or airline timetables. The need to accommodate leave, illness, and study time as well as conform to the industrial arrangements concerning employment of individual trainee medical officers makes developing rosters for most surgical units a nightmare. This is because the hours dictated by the industrial awards within many States of Australia were devised by tribunals with little regard for the day-to-day functioning of hospitals and their need to provide 24-hour coverage for the patients. Nonetheless, rostering has been achieved to meet most of the rules and regulations, and has led to an increased number of trainees being accommodated within the system to provide appropriate junior staffing within the public hospital sector. Patient care. At this stage, it is unclear whether patient care has suffered as a result of these substantial changes in surgical staffing arrangements. Poor outcomes have occurred, but whether these would truly have been prevented by reverting to the old days of exhausted trainees, barely able to stay awake at the end of a 36-hour shift and caring for too many patients, is probably questionable. On the whole, patient care has probably been protected by an increasing involvement of the consultant medical staff in the close surveillance of patients under their
Surgery Volume 134, Number 1
direct management. It has also led to a small but increasing number of full-time staff specialists being appointed within major public hospitals to ensure that day-to-day decisions can be made in a timely and responsible fashion. It may even be that the change in junior staffing hours has led to improved patient care as more senior members of staff have become involved directly in the decision-making that had been left to more junior members of staff. Surgical experience. Despite all these changes, the actual case load passing through the public hospital system has not altered substantially. At the same time, the number of individuals providing surgical care within the hospital system has increased. This has led to considerable competition for the surgical cases available to provide an appropriate surgical experience during the course of training. The lack of long hours through the night to cover the emergency load has probably had very little impact on surgical experience for many surgical trainees. It would seem doubtful, after the first dozen or so perianal abscesses or lacerated scalps, that much could be learned from the next 50 or 60 such cases. Most major surgery, and certainly complex surgical problems, are managed during daylight hours, and these cases can all be presented to the junior staff working within the hospital. Surgery around the world has yet to determine the minimum number of cases one must handle to become a competent surgeon.1 Before presenting for the Part II Australian Fellowship in general surgery, trainees must have been involved with at least 500 major cases and 100 endoscopies and 50 colonoscopies.2 Surgical competence is probably a very variable factor, depending more on the individual than any mandated number that can be established. Nonetheless, because competition for exposure to a range of operative situations has increased, it has become essential that all cases performed within the public hospital system be offered to junior staff under direct consultant supervision. When this occurs, there is a slowing down in the number of patients who can be treated, with associated impact on the case mix volume passing through institutions. This cost of training is an area that is now beginning to challenge hospital administrators and health authorities as they attempt to understand the real costs associated with having trainee doctors rather than experienced consultants performing surgery within their facility. From a purely cost-benefit point of view, it would be better that all cases were performed by consultants with no junior staff involvement. However, such an approach would destroy surgical training programs and lead to a shortage of sur-
Maddern 25
geons, eventually increasing costs to attract them to health facilities. The analysis, though, is complex and to date has not been successfully conducted within Australia. One area that remains largely untapped but may also become increasingly valuable in providing sufficient surgical experience to trainee surgical staff is the 40% of patients who are privately insured and not usually using the public hospital system. One challenge that remains is to expose trainee surgeons to the interesting and unusual cases being performed in the private health sector to compensate for the potential loss of such cases to trainees within the public hospitals. This area is currently being addressed in some centers and, once an appropriate model has been developed, it will have to be considered for wider introduction. As the number of cases that individual trainees actually handle is reduced, there is a real risk that the length of surgical training will have to be extended. This may not occur formally; however, it will lead to individuals seeking post-fellowship opportunities to gain sufficient clinical experience before becoming consultant surgical staff. These post-fellowship trainees then push pre-fellowship candidates further back in their quest for surgical experience. In Australia the implication is that typically, an individual can finish his or her medical school education by the age of 23 or 24 (unless he pursues a postgraduate training course, which are increasing in number within Australia). He or she would then complete internship and basic surgical training by the age of 27 and surgical training would be concluded, if uninterrupted, by the age of 32 or so. If an additional 2 or 3 years of training, or even more, are required, the individual may well be in his middle to late 30s before he has acquired sufficient experience to practice independently. This extraordinarily long training is a great disincentive to many individuals, particularly women, who see it as incompatible with having a family and still finishing training in time to have a worthwhile practicing life ahead. Because of this prolonged period, when surgery is compared with radiology, anesthesia, and general practice, for example, it could be seen as a less desirable option, given the more focused and rapidly concluded training options available in these other specialties. HOW TO MANAGE THE CHALLENGE Is it possible to imagine a hospital structure that can accommodate these reduced working hours, provide excellent teaching, roster patient care, sufficient number of cases, and not lengthen the training? From the outset, it is important that hospitals establish a well-organized preadmission system that
26 Maddern
enables junior staff to attend a group of patients being prepared for their elective admissions for surgery. This enables clear surgical protocols to be developed and implemented, and gives surgical trainees a good opportunity to appreciate the issues involved in surgical preparation, consent, and discharge planning. This approach also helps develop an efficient use of residents’ time to maximize the number of patients seen. Once a patient has been admitted into the hospital system, it is essential that standardized handovers and clear delineation of responsibilities be established for the resident staff. Consultant supervision is essential for this to occur and anything less than complete and relevant handovers cannot be tolerated within the current hospital system. The benefits of such an approach have been to implement an almost ongoing peer review at a junior staff level. This has meant that individual registrars have made sure they have fully acquainted themselves with the details of their patients before handing them over to the surgical colleague. The surgical colleague has the opportunity to review what is being undertaken with the patient and suggest additional investigations, diagnoses, or treatment strategies. It is very difficult in a well-structured handover situation to have ongoing perpetuation of errors unless false information has been unknowingly acquired. Indeed, well-designed handover of patients is a concept that could be extended to consultant staff. The whole concept of individual surgeons providing “continuity of care” may be outdated. Continuity of care will need to be provided by the unit or team, not the individual consultant surgeon, resident, or registrar. It is only through team care that patient safety can be guaranteed under the restrictive working hour trends. However, to provide continuous feedback on patient care and, therefore, a first-rate educational environment, there is an increasing need to have at least one full-time consultant functioning within each surgical unit. This individual must have oversight of all patients being treated by the unit, to the extent that a significant question regarding the care being delivered by one of the visiting medical staff be brought to that individual’s attention by the full-time consultant. Such an environment can lead to resentment and hostility; however, when developed as an educational and peer-review system, it can be seen as a positive interaction. Much of the care provided to surgical patients in the operating room is from surgical trainees; wards, however, are greatly assisted by the placement of interns. Interns are becoming a rare commodity, and the need for other forms of clinical support, such as nurse practitioners, is more evident. Many of
Surgery July 2003
the functions traditionally allocated to intern can be performed better by nurse practitioners familiar with the unit. This would free the interns up for a more general educational experience rather than one dominated by learning idiosyncratic unit policies and performing repetitive clerical functions. The need to provide good quality care for patients means that there is a greater need for more experienced junior medical staff than just the interns. Most public hospital surgical wards now care for a larger number of sicker patients than in the past. This has occurred because of the rapid escalation of ambulant surgery within many parts of surgical practice. Depending on the unit and the hospital, ambulant surgery is provided for 50% to 70% of all patients treated within the public hospital sector. These patients attend during daylight hours and, if their surgery is consultant-supervised, provide an excellent opportunity for staff training if the logistic issues that make junior staff available for these cases can be overcome.3 CONCLUSION The reduction in work hours within the Australian health scene has arrived in a fragmented and poorly coordinated fashion, but its effect has been considerable. The result has not necessarily led to worse health care. Indeed, it may be that because of the clear challenges it provides to surgical teachers within the public hospital sector, better programs will be devised. It is possible that the teaching component of surgical training will be more highly valued as time goes on. Patient care may be enhanced by more peer review and senior clinician involvement; rostering arrangements will lead to less stressed and potentially happier surgical residents; and a greater priority will be placed on using all patients passing through the system as potential teaching opportunities. There will never be a return to the number of hours worked by junior staff in the past, and it is reasonable to predict that with the change in trainee demographics (increasing age and more women), working hours will continue to decrease. The next generation of specialists will have completely different work expectations, and innovative training programs will be needed to meet the challenge. REFERENCES 1. Harder F. “I would like to be a surgeon, but …”. Ann Surg 2002; 236(6):699-702. 2. The Royal Australasian College of Surgeons. The surgical training programme in general surgery —regulations. Available from: http://www.racs.edu.au/edu/training/ reg.html 3. Bruening M, Maddern GJ. Undergraduate surgical education in an ambulatory surgery setting. Amb Surg 2001; 9:155-8.