By Michael Richman, MD, FACS
Nearly one year ago, in a blog published on WebMD, I addressed the concerns of medical training that interns and residents endure while on their journey to gain board certification as a physician or a surgeon. Now, new information collected from a recent study of 215 interns in 11 general surgery residence programs outlines the efficacy of the new standards. I felt that the former study hampered the ability of newly trained doctors to deal with real-world medicine after they completed their training. Required residency hours were lengthy and medical professional communities recognized the potential dangers that excessive work hours under stressful situations posed on several levels, including sleep deprivation and the resulting increased rates of medical errors due to fatigue.
In 2003, in an effort to further regulate, the Accreditation Council for Graduate Medical Education (ACGME) looked at the current residency programs. This included studying the amount of time residents were required to spend at the hospital, patient safety issues, resident wellness, and the resident training experience. In 2007 medical residents were restricted to 80 hours per week, overnight call frequency could be no more than one overnight every third day, straight shifts were a maximum of 30 hours, and residents had 10 hours off between shifts. Although these rules were voluntary, adherence had been mandated for the purposes of accreditation of the residency. Moreover, first-year residents, also called interns, were limited to shifts no longer than 16 hours straight due to these newly regulated standards effective on July 1, 2011.
While patient safety advocates and surgeons themselves voiced objections and trepidation, the ACGME still implemented the new standards in an effort to protect residents from sleep deprivation, fatigue, and the medical errors that can follow. Second-year resident schedules allowed up to 24 straight hours of work, with 4 additional hours permitted to ensure proper patient hand-off, as opposed to the previous standards in which 24-hour shifts were the maximum for all residents, with 6 hours acceptable for patient hand-off.
With all the debate and protest, David Farley, MD, of the Mayo Clinic in Rochester, Minn., and his colleagues conducted a thorough study and his findings were published in the June 18, 2012 edition of the Archives of Surgery, along with statistics that caused alarm within the medical community and indicate potential adverse effects on patient care.
The investigation found that 80% of the surgical interns believed that the time restrictions would decrease continuity of care with patients, and nearly 58% believed that it would impact overall patient care. Furthermore, even greater concern was expressed when interns were asked about the effect the reduced hours would have on their expertise in the operating room, with 67% reporting apprehension. On average, 50% of the interns believed their general medical knowledge, surgical skill set, and educational experience would suffer, even if their fatigue would lessen.
Farley’s findings reiterate my opinions regarding the deficiencies in medical training in the United States since I was a medical resident. After four years of medical school and nine more years of surgical training after that, I went into private practice as a heart surgeon in 1999. I did my general surgery training at Los Angeles County-USC Medical Center, which is probably the busiest hospital in the U.S. I performed over 1300 cases as the primary surgeon in four years and often spent 130 hours a week at the hospital. I did my heart surgery training at University of Miami-Jackson Memorial Hospital, which also is one of the busiest hospitals in the United States. Today, the graduating residents from the same general surgery program I trained at finish with around half the number of cases that I performed in the same time frame of training.
There is a reason that surgical training is accordingly extensive and complex. The first reason is to purge those doctors that can’t perform under such extreme conditions. The second reason is that in order to develop an excellent technical skill set in the operating room, there needs to be a graded approach to learn how to operate such that residents can care for patients independently at the end of residency. In most residency programs today, residents are only allowed to do a portion of the case because the attending surgeon completes the surgical procedure. In addition, many procedures that were done “open” in the past are now done using minimally invasive techniques. Therefore, when a complicated procedure mandates performing it in an open fashion, future surgeons may not have had any experience learning how to do an operation in this manner. Operating on simulators is not the same as operating on the human body. After graduation, how are these surgeons going to face a sick patient “alone” if they haven’t successfully performed the required procedures for board certification with great frequency and using all the techniques?
As I stated in my previous WebMD article, “What Kind of Doctors Are We Training for the Future?” many times operative procedures and the care of sick patients are performed under exhausting conditions, and mistakes may be made. I believe that fatigue is not the primary cause of mistakes, but rather mistakes are due to insufficient experience performing surgical procedures and caring for a large number of critically ill patients at one time. Furthermore, since residents no longer have to make many decisions independently, they are not equipped to enter real-world surgery where there may not be anybody to help with complicated decision making. Finally, the new rules that have been put in place have turned the surgical field into a “shift” mentality, which minimizes accountability and goes against the fundamental reasons why one decides to pursue a surgical career.
As I stated in my prior article, “With a shortened work week, now at 70 hours, there can be no accountability on the part of residents, since as soon as the ‘going gets tough,’ they’re allowed to go home. In the real world, sick patients are not on a 9 to 5 schedule. Does anybody ever think why it takes so long to become a navy fighter pilot? Does one ever think that mistakes are made due to pilot fatigue? The answer to the last question should be obvious, but the difficult, grueling, repetitive training minimizes this, as it does in surgical training.”
So what kind of doctors are we training for the future? It is imperative that current surgical training be rigorously scrutinized. Unless we individualize the training that is required of each specific specialty, the future of medicine, as we currently know it, is doomed to failure. Surgical care has many shades of gray and cannot be made into a black-and-white issue. To limit work hours and allow future surgeons to believe that delegating responsibility is the norm assumes that all residents are created equal and does not allow any flexibility in the way surgery residents are trained. This makes further specialized post-residency training almost mandatory in a narrow surgical field just so a future surgeon can master the skills that should have been taught during their general surgical residency. Unless we confront the reality of current medical training and the future of health care, we are heading for a health care system that is inferior to that of many other countries. The current health care law was supposedly made to provide excellent care to all Americans while cutting costs. Unfortunately, this notion actually creates a dichotomy because poorly trained surgeons will rely on more and more testing on more people who now will have insurance in order to make a diagnosis that could be made by simple examination, if only the doctor knew how to perform that examination properly. The art of physical diagnosis by examining the human body has been replaced by tests that are often unnecessary and are very costly. Residency training needs to be extended if the current system remains and surgeons need to be compensated appropriately after spending a majority of their life studying, training, and making little or no money.