Duty Hour Limits Slash Surgical Caseloads

Yael Waknine

July 10, 2013

Duty hour restrictions on first-year general surgery residents have been linked to a 25.8% reduction in operating case load, according to a study published online July 10 in JAMA Surgery.

The findings represent the first published data on the effects of the 16-hour cap implemented by the Accreditation Council for Graduate Medical Education in July 2011, the authors report.

"If the 16-hour shift were to be extended to all postgraduate year levels, one can anticipate that additional years of training will be needed to maintain the same operative volume," write Samuel I. Schwartz, MD, from the Harbor-University of California at Los Angeles Medical Center, Torrance, and colleagues.

Analyzing data for 249 first-year residents in 10 US programs, the researchers found that interns limited to 16-hour shifts logged 65.9 cases compared with an average of 88.8 cases in the preceding 4 academic years (P = .005).

Participation in major and first-assistant cases decreased by 31.8% (54.9 vs 80.5; P < .001) and 46.3% (11.1 vs 20.7; P = .008), respectively compared with the preceding 4 academic years.

Most surgical categories were affected, including abdominal (15.1 vs 21.9; P = .03), soft tissue/skin/breast (14.5 vs 19.3; P = .05), and basic laparoscopic procedures (; 8.7 vs 14.0; P = .03).

Interns also had significantly decreased access to less commonly performed endocrine (0.2 vs 0.9; P = .004), head/neck (1.5 vs 3.1; P = .001), complex laparoscopic (2.5 vs 6.8; P = .005), pediatric (1.3 vs 4.9; P < .001), and thoracic surgeries (1.5 vs 4.4; P = .005). There was no change in experience with liver, pancreas, trauma, and vascular.

According to the authors, the results are in some respects surprising, given that the overall 80-hour work week remained constant. The discrepancy may be a result of an increased number of residents assigned to night shifts bereft of surgical opportunity.

"[I]n the present study, the 10 program directors reported that the predominant solution to the 16-hour rule was an expansion of the night-float system to services previously covered by home call," the authors write. They note that the 14-hour functional service time (to allow for the requisite 10-hour break) further reduces intern contact hours.

In an accompanying editorial, Julie Ann Freischlag, MD, from the Department of Surgery at Johns Hopkins Medical Institutions in Baltimore, Maryland, who was not involved in the study, suggests that a more efficient use of shift time may produce a spike in case loads, "at least for the day intern."

"We need to master the ability to fill every hour of every day with meaningful activity for interns," Dr. Freischlag writes. Key elements may include recognition among students and staff that first-year residents need to get into the operating room for at least 3 cases each week; freeing up residents' time by shifting floor work, clinics, and intensive care unit coverage to other healthcare workers; and encouraging faculty to allow interns hands-on experience in the operating room.

This study previously was presented at the 84th Annual Meeting of the Pacific Coast Surgical Association in Kauai, Hawaii, on February 17, 2013. The authors and editorialist have disclosed no relevant financial relationships

JAMA Surg. Published online July 10, 2013.

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