- Email: [email protected]
Resident Work Hours: Is There Such a Thing as a Free Lunch?
among today’s generation of students as seen in the consistent decline of applicants seeking surgical training. Do we want to further erode the sense of commitment among our future surgeons? The ACGME mandate is a danger to the future of our profession. As programs seek solutions that comply with an 80-hour workweek, we must remain cognizant of the core values of our profession, which include efficient training that allows residents to take advantage of a unique learning environment and maintain a commitment to continuity of patient care. A new era in surgical training is here, requiring all of us to become proactive and creative
to maintain the excellence of our profession. If we do not meet this challenge, our profession significantly risks the ability to produce a “few good men and women” able to provide the type of highquality surgical care and commitment to patients that exemplify our profession. If we do not meet this challenge, external bodies will assume increased control over our profession, further restricting our ability to produce competent surgeons. If we do not meet this challenge, everyone loses. doi:10.1016/S0149-7944(03)00055-2
Resident Work Hours: Is There Such a Thing as a Free Lunch? Donald M. Botta, Jr, MD, Department of Surgery, University of Tennessee Memphis, Chattanooga Unit of the College of Medicine, Chattanooga, Tennessee When I was growing up, I remember vividly having been told, “there ain’t no such thing as a free lunch.” I came to understand that any lunch that was had was paid for by someone. More importantly, by not working to earn that lunch, the recipient is paying a price also. As our program has begun trying to implement the 80-hour work-week requirement that will soon be mandated, those words have rung true once again. Two lessons have come from our initial attempts at trimming hours. First, the work does not go away. As our residents are leaving the hospital sooner and taking less call, the junior residents who are here, and our more senior residents, are taking up the slack. Second, there has been, for lack of better words, a loss of ownership of the work, thus a lack of the sense of personal responsibility for taking care of the things that need to be done to care for our patients. As it gets late in the day, when residents used to look at their respective patient lists to see what was left to do prior to going home, they now look at their respective watches to see when they can go home, and look at their list to see what needs to be “checked out” to the call team. This academic year is the first time that I have been paged to be informed that it is time to check out. This mentality is not only detrimental to patient care, but also it interferes with the fostering of the work ethic that is required to develop into a surgeon. The medicine team at our hospital has fully integrated the work hours requirements into their program. As such, they have become quite proficient with the “night float” system. It would tax my mathematical ability to calculate the number of times
Correspondence: Inquiries to Donald M. Botta, Jr, MD, Department of Surgery, University of Tennessee Memphis, Chattanooga Unit of the College of Medicine, 979 East 3rd Street, Suite 401, Chattanooga, TN 37403; fax: (423) 778-2950; e-mail: [email protected]
320
Donald M. Botta, Jr, MD
my team has received the usual 4:30 P.M. consult (delivered by the nursing staff), and when we call the duty medical resident to find out more about the patient having been told, “Oh I’m not following that patient, he was just checked out to me.” Even better is trying to get a medical consultation after hours, only to be informed that the medicine team is “capped,” and can accept no more patients. This system has, however, freed up the medicine residents to do a heroic amount of moonlighting. Surgery is different from other fields of medicine. The American public expects their surgeons to be superhuman. There is no other field that requires the diligence, number of years of training, number of hours per year, or amount of technical expertise to reach entry level than surgery. The product of this CURRENT SURGERY • Volume 60/Number 3 • May/June 2003
training, although not superhuman, is probably as close as can be produced, and it does not come cheap. Surgery is a body of knowledge that is growing in depth and volume by the day. Consideration is being given to actually shortening surgical training programs. When one combines this with the 80-hour work week, one must ask, “What kind of surgeons will be graduating 10 years from now?” Do surgical residents need to work fewer hours for patients’ safety sake? Show me the data. A PubMed search this month on the subject “resident work hours” returned 98 listings. None, however, represented prospective studies that linked long duty periods with adverse patient outcomes. Moreover, it seems more likely that patients will be hurt by incomplete “checkouts.” All of that being said, here a few of the changes that we have made that have been useful in limiting work, while minimally detracting from the educational experience of the resident. ● Our trauma team now has a hospital-funded discharge summary service, which is largely staffed by residents in their newfound free time. This actually does take a fair amount of the workload off of our residents, and they can become proficient at discharge summaries on other services. ● The residents on the trauma team now get a “virtual weekend” midweek, so that we have more coverage during the weekends, which are the busiest time for the trauma team. ● Flexion/extension cervical spine radiologic examinations are now supervised by our trauma nurse specialists, who also assist to a limited extent with floor rounds. ● Our trauma junior residents have gone from every other night call to every third night call. ● When the trauma team is overwhelmed, they are quicker to call for help from the other in-house surgical services.
● Our critical care residents are now on every third night call, instead of every other, leaving 1 of 3 nights covered by the trauma chief resident. ● Our junior residents are doing more cross covering for other services at night, so that now, instead of 5 junior residents in house, we usually have 3. Have the changes produced residents that are happier? My guess would be no. They certainly have to put up with many more of the “when I was an intern” comments than in the past. Has quality suffered? I have no hard data on which to base a conclusion, but my guess is yes. With notable exceptions, this intern class has shown a trend toward a smaller fund of knowledge, less facility with procedures, and a less admirable work ethic than those with whom I have worked in the past. Curtailing resident work hours will certainly make surgery more attractive to prospective applicants who are concerned about “lifestyle issues,” expanding the number of applicants to surgical programs. One must ask, however, if these are the people that we want to be our future surgeons. The challenge for program directors is to implement the new requirements in a way that will not adversely affect the work ethic that is instilled in surgery programs today. If they do not succeed, then the only group who will benefit from these measures is the trial lawyers. Ten years from now when Dr. Jones, fresh out of residency, does a late afternoon case after being up all night operating for the first time in his life, and the patient has a less than perfect outcome, he may ponder to himself while sitting in the witness chair, “maybe that lunch wasn’t free after all.” doi:10.1016/S0149-7944(03)00054-0
Surgical Training, the Revolution: Work Hours Limitations Michael J. Goldstein, MD, Department of Surgery, New York Presbyterian Hospital, Columbia Campus, New York, New York Sucorrgical training began in Europe with apprenticeships, guided by early surgical pioneers such as Bernhard Rudolf Konrad von Langenbeck in the 19th century. Skills were developed, and techniques were passed from master surgeon to apprentice with mentoring and without monitoring. In this country, William Stewart Halsted changed the model to suit the needs of the newly conceived university medical Correspondence: Inquiries to Michael J. Goldstein, MD, Department of Surgery, 177 Fort Washington Avenue, Milstein Hospital Building, 7GS-313, New York, NY 10032; fax: (212) 305-8321; e-mail: [email protected]
CURRENT SURGERY • Volume 60/Number 3 • May/June 2003
schools and closely affiliated university hospitals. No longer was the trainee an employee of a single surgeon working along with him, but rather an employee of a hospital, responsible for the care of patients of multiple physicians. As the volume of surgery has grown vastly from the 1880s to the present, the workload has grown without any direct tie-in to educational needs. Looked at rationally, surgical training had evolved from an apprenticeship to a residency, with a shift from indentured servitude to an individual surgeon with defined work hours, to institutions with insatiable and unregulated ability to set the work day and night. 321
to maintain the excellence of our profession. If we do not meet this challenge, our profession significantly risks the ability to produce a “few good men and women” able to provide the type of highquality surgical care and commitment to patients that exemplify our profession. If we do not meet this challenge, external bodies will assume increased control over our profession, further restricting our ability to produce competent surgeons. If we do not meet this challenge, everyone loses. doi:10.1016/S0149-7944(03)00055-2
Resident Work Hours: Is There Such a Thing as a Free Lunch? Donald M. Botta, Jr, MD, Department of Surgery, University of Tennessee Memphis, Chattanooga Unit of the College of Medicine, Chattanooga, Tennessee When I was growing up, I remember vividly having been told, “there ain’t no such thing as a free lunch.” I came to understand that any lunch that was had was paid for by someone. More importantly, by not working to earn that lunch, the recipient is paying a price also. As our program has begun trying to implement the 80-hour work-week requirement that will soon be mandated, those words have rung true once again. Two lessons have come from our initial attempts at trimming hours. First, the work does not go away. As our residents are leaving the hospital sooner and taking less call, the junior residents who are here, and our more senior residents, are taking up the slack. Second, there has been, for lack of better words, a loss of ownership of the work, thus a lack of the sense of personal responsibility for taking care of the things that need to be done to care for our patients. As it gets late in the day, when residents used to look at their respective patient lists to see what was left to do prior to going home, they now look at their respective watches to see when they can go home, and look at their list to see what needs to be “checked out” to the call team. This academic year is the first time that I have been paged to be informed that it is time to check out. This mentality is not only detrimental to patient care, but also it interferes with the fostering of the work ethic that is required to develop into a surgeon. The medicine team at our hospital has fully integrated the work hours requirements into their program. As such, they have become quite proficient with the “night float” system. It would tax my mathematical ability to calculate the number of times
Correspondence: Inquiries to Donald M. Botta, Jr, MD, Department of Surgery, University of Tennessee Memphis, Chattanooga Unit of the College of Medicine, 979 East 3rd Street, Suite 401, Chattanooga, TN 37403; fax: (423) 778-2950; e-mail: [email protected]
320
Donald M. Botta, Jr, MD
my team has received the usual 4:30 P.M. consult (delivered by the nursing staff), and when we call the duty medical resident to find out more about the patient having been told, “Oh I’m not following that patient, he was just checked out to me.” Even better is trying to get a medical consultation after hours, only to be informed that the medicine team is “capped,” and can accept no more patients. This system has, however, freed up the medicine residents to do a heroic amount of moonlighting. Surgery is different from other fields of medicine. The American public expects their surgeons to be superhuman. There is no other field that requires the diligence, number of years of training, number of hours per year, or amount of technical expertise to reach entry level than surgery. The product of this CURRENT SURGERY • Volume 60/Number 3 • May/June 2003
training, although not superhuman, is probably as close as can be produced, and it does not come cheap. Surgery is a body of knowledge that is growing in depth and volume by the day. Consideration is being given to actually shortening surgical training programs. When one combines this with the 80-hour work week, one must ask, “What kind of surgeons will be graduating 10 years from now?” Do surgical residents need to work fewer hours for patients’ safety sake? Show me the data. A PubMed search this month on the subject “resident work hours” returned 98 listings. None, however, represented prospective studies that linked long duty periods with adverse patient outcomes. Moreover, it seems more likely that patients will be hurt by incomplete “checkouts.” All of that being said, here a few of the changes that we have made that have been useful in limiting work, while minimally detracting from the educational experience of the resident. ● Our trauma team now has a hospital-funded discharge summary service, which is largely staffed by residents in their newfound free time. This actually does take a fair amount of the workload off of our residents, and they can become proficient at discharge summaries on other services. ● The residents on the trauma team now get a “virtual weekend” midweek, so that we have more coverage during the weekends, which are the busiest time for the trauma team. ● Flexion/extension cervical spine radiologic examinations are now supervised by our trauma nurse specialists, who also assist to a limited extent with floor rounds. ● Our trauma junior residents have gone from every other night call to every third night call. ● When the trauma team is overwhelmed, they are quicker to call for help from the other in-house surgical services.
● Our critical care residents are now on every third night call, instead of every other, leaving 1 of 3 nights covered by the trauma chief resident. ● Our junior residents are doing more cross covering for other services at night, so that now, instead of 5 junior residents in house, we usually have 3. Have the changes produced residents that are happier? My guess would be no. They certainly have to put up with many more of the “when I was an intern” comments than in the past. Has quality suffered? I have no hard data on which to base a conclusion, but my guess is yes. With notable exceptions, this intern class has shown a trend toward a smaller fund of knowledge, less facility with procedures, and a less admirable work ethic than those with whom I have worked in the past. Curtailing resident work hours will certainly make surgery more attractive to prospective applicants who are concerned about “lifestyle issues,” expanding the number of applicants to surgical programs. One must ask, however, if these are the people that we want to be our future surgeons. The challenge for program directors is to implement the new requirements in a way that will not adversely affect the work ethic that is instilled in surgery programs today. If they do not succeed, then the only group who will benefit from these measures is the trial lawyers. Ten years from now when Dr. Jones, fresh out of residency, does a late afternoon case after being up all night operating for the first time in his life, and the patient has a less than perfect outcome, he may ponder to himself while sitting in the witness chair, “maybe that lunch wasn’t free after all.” doi:10.1016/S0149-7944(03)00054-0
Surgical Training, the Revolution: Work Hours Limitations Michael J. Goldstein, MD, Department of Surgery, New York Presbyterian Hospital, Columbia Campus, New York, New York Sucorrgical training began in Europe with apprenticeships, guided by early surgical pioneers such as Bernhard Rudolf Konrad von Langenbeck in the 19th century. Skills were developed, and techniques were passed from master surgeon to apprentice with mentoring and without monitoring. In this country, William Stewart Halsted changed the model to suit the needs of the newly conceived university medical Correspondence: Inquiries to Michael J. Goldstein, MD, Department of Surgery, 177 Fort Washington Avenue, Milstein Hospital Building, 7GS-313, New York, NY 10032; fax: (212) 305-8321; e-mail: [email protected]
CURRENT SURGERY • Volume 60/Number 3 • May/June 2003
schools and closely affiliated university hospitals. No longer was the trainee an employee of a single surgeon working along with him, but rather an employee of a hospital, responsible for the care of patients of multiple physicians. As the volume of surgery has grown vastly from the 1880s to the present, the workload has grown without any direct tie-in to educational needs. Looked at rationally, surgical training had evolved from an apprenticeship to a residency, with a shift from indentured servitude to an individual surgeon with defined work hours, to institutions with insatiable and unregulated ability to set the work day and night. 321