Surgery News - June 2008 - (Page 6)

6 OPINION EDITORIAL SURGERY NEWS • J U N E 2 0 0 8 Shifting Down were made of Back when ships wood and men were made of steel, I was an intern at a hospital that didn’t worry much about duty hours. On call responsibility was simple: you were on call 24/7, but you could sign out to another intern for a few hours on weekends if your BY LAZAR J. GREENFIELD, M.D., FACS patients were stable. Some patients required minimal care, because hernias and breast biopsies kept them in the hospital for a few days. Others were very sick, however, and ICUs had not been invented. Living in a hospital apartment, we never worried about a phone bill because our number was a hospital extension. Interns did all routine lab work, started IVs, and scrubbed in on all elective and emergency cases. To say we were sleep deprived is an understatement. We fell asleep holding retractors in the OR and during conferences. Did this system need reform? You bet. Succeeding programs demonstrated that excellent clinical experience could be obtained with scheduled time off, and that residents learned more while awake. The reform process became a public issue in 1986 after 18-year-old Libby Zion American College of Surgeons 94th annual Clinical Congress October 12–16, 2008: San Francisco, CA Moscone Convention Center Save the Date! Join us in San Francisco for the 94th annual Clinical Congress. As always, it will be an educational opportunity you won’t want to miss! Please be sure to visit www.facs.org in the coming months for more details regarding the educational program, registration, housing, and transportation. died of a drug interaction in New York under the care of poorly supervised and inexperienced residents. Her father, a newspaper columnist, believed fatigue was the problem, and embarked on a crusade resulting in state laws enacted in 1989 that restricted resident duty to 80 hours per week, on-call duty to every third night, and individual shifts to 24 hours. These restrictions became national after Public Citizen, a Washington-based nonprofit public interest organization, petitioned the Occupational Safety and Health Administration on behalf of several medical resident and student organizations in 2001 to take control of residency programs. Rep. John Dingell (D-Mich.) supported legislation advocating unionization of all residents. The Accreditation Council for Graduate Medical Education responded quickly by endorsing the restrictions and applying them to all training programs in 2003 to avoid federal control. The restrictions facilitated recruitment of medical students to surgical programs and forced programs to eliminate much of the noneducational busywork. But continuity of care under shift management and overall clinical experience were challenged. Fatigue-related errors declined, errors related to miscommunication, continuity of care, and cross-coverage availability increased ( J. Surg. Res. 2006;135:275-81). Studies of overall operative experience generally showed little change—although residents knew less about their patients (Am. Surg. 2005;71:552-5). Rep. Dingell has asked the Institute of Medicine to form a committee to propose new guidelines in 2009 further reducing resident workload. The committee has heard testimony about fatigue-related errors, sleep deprivation, and the increase in auto accidents. An American College of Surgeons task force developed a report and presented it to the IOM in March (see p. 4). Among other recommendations, the report emphasized the need for a multi-institutional study to fully understand the impact of further duty hour limitations before changing current requirements. On an emotional level, the plight of residents is appealing. But the core issues of patient safety and adequacy of clinical experience are inadequately documented. Regardless of the issue, when reformers seek change, the pendulum is pushed as far as it will go. Then the effects are measured, and the pendulum usually swings back. In August 2009, the European Working Time Directive will reduce duty hours from the current 56 to 48 per week. Program directors there, concerned about adequacy of clinical experience, are considering extending the length of training. No one knows the optimal range of duty hours, but we do know the consequences of inadequate training and passerby patient care. So who do you want standing over you when you’re on an OR table—a smiling, inexperienced surgeon or a tired surgeon with experience? DR. GREENFIELD is editor in chief of SURGERY NEWS. http://www.facs.org http://www.facs.org

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Surgery News - June 2008 Contents Work Hours New Digs Banking Blood Improved Imaging

Surgery News - June 2008

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