Surgical Residents Dislike Duty Hour Regulations

Laurie Barclay, MD

May 15, 2013

The majority (66%) of surgical residents disapprove of 2011 Accreditation Council for Graduate Medical Education (ACGME) Common Program requirements, according to a survey published online May 15 and in the May issue of JAMA Surgery. The residents surveyed cited worse education, preparation for senior roles, and work schedules after ACGME implementation.

"In 2010, the [ACGME] proposed increased regulation of work hours and supervision for residents," write Brian C. Drolet, MD, from Rhode Island Hospital in Providence, and colleagues. "New Common Program requirements that took effect in July 2011 dramatically changed the customary 24-hour in-house call schedule. Surgical residents are more likely to be affected by these duty hour restrictions."

Six months after implementation of 2011 ACGME regulations, residents voluntarily completed a 20-question electronic survey regarding their perceptions of changes in education, patient care, and quality of life, as well as their compliance with duty hour regulations. From a demographically representative sample of 6202 survey respondents, the investigators identified a subset of 1013 residents in general surgery and surgical specialties at 123 ACGME-accredited teaching hospitals in the United States and US territories.

After implementation of the 2011 regulations, most surgical residents felt that education (55.1%), preparation for senior roles (68.4%), and work schedules (50.7%) had worsened. In contrast, they perceived no change in supervision (80.8%), safety of patient care (53.4%), or amount of rest (57.8%).

Most residents surveyed responded that quality of life after implementation was worse for senior residents (54.4%) but better for interns (61.9%). Other negative effects of implementation were increased handoffs (78.2%), a shift of junior-level responsibilities to senior residents (68.7%), noncompliance (67.6%), and duty hour falsification (62.1%).

"A majority of surgical residents disapprove of 2011 ACGME Common Program requirements (65.9%)," the study authors write. "The proposed benefits of the increased duty hour restrictions — improved education, patient care, and quality of life — have ostensibly not borne out in surgical training. It may be difficult for residents, particularly in surgical fields, to learn and care for patients under the 2011 ACGME regulations."

Limitations of this study include a low response rate, the evaluation of intern responses to a system for which they have no basis for comparison, and difficulty quantifying the educational experience of residents and effects on patient care.

"We propose a training model that emphasizes continuity through extended duty periods and greater scheduling flexibility while imposing reasonable limits on shifts," the study authors conclude. "Junior residents should have graduated levels of responsibility with decreasing shift regulations throughout the intern year, appropriately available supervision, and — most important — mentorship, as deemed by program directors and senior residents. Finally, we would model the chief resident experience after call systems for attending surgeons, emphasizing greater home call and patient management responsibility, with the goal to prepare residents adequately for a transition to the independent practice of surgery."

In an invited critique, Orlando C. Kirton, MD, from Hartford Hospital in Connecticut, notes the study limitations and his concerns about reported noncompliance with ACGME regulations. He recommends development and implementation of new education paradigms and goal- or milestone-based educational principles.

However, he is "optimistic the future is bright for surgical education and that duty hours should not negatively affect the resident experience."

The study authors and Dr. Kirton have disclosed no relevant financial relationships.

JAMA Surg. 2013;148:427-434. Article abstract, Critique extract


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