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Rules Will Hurt Training, Surgery Interns Say

Restrictions on the length of time that residents can be on duty will have a negative impact on the quality of training, surveyed surgical interns said.

Most believed that new regulations would diminish continuity of care (80%), time spent in the operating room (67%) and development of their surgical skills (53%), David Farley, MD, of the Mayo Clinic in Rochester, Minn., and colleagues reported in the June issue of the Archives of Surgery.

"As residency programs attempt to adapt to the new regulations, surgical interns have significant concerns about the implications of these regulations on their training," they wrote.

On July 1, 2011, the Accreditation Council for Graduate Medical Education (ACGME) implemented new duty-hour standards for residents, which include a 16-hour shift maximum for postgraduate first-year residents.

Several medical organizations have issued statements against the ruling, saying there's little evidence that extended resident work hours negatively affect patient safety.

Surgeons in particular have debated the relevance of these standards to their specialty. A previous survey showed that surgery program directors said the standards will harm their students' knowledge acquisition and performance.

So to assess the views of surgical interns themselves, Farley and colleagues conducted a survey of 11 general surgery residency programs totaling 215 interns; they had an 83% response rate.

The investigators found that most interns believed the new restrictions will decrease continuity with patients (80.3%), time spent in the operating room (67.4%), and coordination of patient care (57.6%).

They also believed the changes will decrease their acquisition of medical knowledge (48%), their development of surgical skills (52.8%), and their overall educational experience (51.1%).

On the other hand, most believed the changes will improve or won't alter the following aspects of training:

  • Quality and safety of patient care (66.5%)
  • Effective communication with patients, families, and other health professionals (72.1%)
  • Self-evaluation of residents' own patient care (74.7%)
  • Responsiveness to patient needs that supersede self-interest (70.2%)

Also, most agreed that the new standards will diminish resident fatigue (61.5%).

These views were different from those of program directors, reported in a previous survey; significantly higher proportions of interns felt the restrictions wouldn't affect or would even improve quality and safety of care, communication, self-evaluation, and responsiveness to patient needs (P<0.001).

And significantly more program directors believed that fatigue would remain unchanged or would increase with the new standards (P<0.001).

Both groups generally agreed, however, that the changes would diminish the continuity of patient care.

Farley and colleagues cautioned that the study was limited by the potential for response bias, and because it included only two programs from the Northeast region.

Indeed, in an invited critique, Mark Friedell, MD, of the University of Missouri in Kansas City, wrote that eliminating two study limitations could change the results, noting that most programs surveyed were from large universities.

"I suspect that those residents would be less concerned about duty-hour restrictions -- because more of them subsequently chose to do fellowships and are less likely to go straight into general surgery practice -- than those from non-university or community programs," he wrote.

Also, a large proportion of those surveyed were preliminary interns who hadn't yet specialized, he added, noting that those who had were more concerned about continuity of patient care and less likely to believe that fatigue would be diminished.

In an accompanying editorial, Frederic Hafferty, PhD, of the Mayo Clinic in Rochester, Minn., emphasized that the "naysayer" views of some interns and program directors who believe that education quality will not be impacted by the work-hour restrictions should be investigated.

"They see something that the modal majority does not," Hafferty wrote. "They could be wrong, but I suspect not entirely so, and if they are right, they are right in a big way."

He concluded that there's "considerable likelihood that we can learn quite a lot from these voices, but only if we are willing to take that occasional and unconventional walk on the wild side of an alternative future."

Primary source: Archives of Surgery            

Source reference: Antiel RM, et al "Surgical training, duty-hour restrictions, and implications for meeting the Accreditation Council for Graduate Medical Education Core Competencies" Arch Surg 2012; 147(6): 536-541.

Additional source: Archives of Surgery

Source reference: Friedell ML, et al "A triumph of hope over experience?" Arch Surg 2012; 147(6): 541.

Additional source: Archives of Surgery   

Source reference: Hafferty FW, et al "Duty hours, distant voices, and an alternative future" Arch Surg 2012; 147(6): 496-497.

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