For surgical residents, also known as interns or surgeons-in-training, learning how to stay alert through long shifts is just as important as any medical skill. But new data suggests Canada's future surgeons and their patients may actually be better off without work-hour restrictions.
It's not out of the ordinary for surgical residents to work 30-hour shifts and 100-hour weeks. That's time spent learning crucial skills — how to cut, stitch, and identify anatomy in the operating room — that can make or break a career.
Medical resident work hours came into the spotlight in 1984, when 18-year old Libby Zion died unexpectedly in a New York hospital – a tragedy that an investigation found was partly the result of overworked medical interns. Ongoing concerns about similar incidents prompted the United States and Quebec to cap the number of hours that trainees could work.
But new research is showing the caps may be having some unintended side-effects.
A Canadian-led international study published in the Annals of Surgery in March -- which consolidated the results of 135 prior studies examining the impact of work-hour restrictions on medical residents in the U.S. and Quebec — showed that surgical trainees facing mandatory limits on their work-hours had lower scores on their licensing exams. It's a sign that the young surgeons may not have had enough hours at work to learn all they need to know.
"Strict work-hour limits prevent surgical trainees from spending enough time practising in the operating room," says Dr. James Rutka, one of the lead authors of the study and the Chair of the Department of Surgery at the University of Toronto.
Dr. James Rutka, Chair of the Department of Surgery at the University of Toronto, says shorter and more frequent shifts mean residents are constantly handing over patient information to other teams, increasing the chance of miscommunication and medical error. (Courtesy James Rutka)
"If we want to train board certified surgeons in five years, trainees need to be able to choose if they want to work a little longer to learn what they need to know," Rutka says, pointing out that every resident learns at a different pace.
What's more, the study said surgical residents weren't necessarily better rested, and limiting work hours hasn't improved patient safety. In some cases, the study said, it may even be responsible for a higher number of patient complications -- like infections and blood clots after surgery.
Shorter shifts also mean that residents are more frequently handing over patient treatment information to incoming teams, increasing the chance for miscommunication and medical error, Rutka says.
As a result, residents on capped shifts know much less about each patient. And being familiar with a patient's medical history is critical to a resident's ability to avoid mistakes and realize when a patient's condition is deteriorating.
Another report, published on Tuesday in the Canadian Medical Association Journal, also suggests that work-hour restrictions aren't good for residents and patients. Authors pointed to more frequent patient handovers among doctors changing shifts as a major cause of medical errors. Shorter shifts also meant residents ended up working more shifts per week and didn't have as much time to sleep.
Intern perspective
Surprisingly perhaps, many surgical residents agree there shouldn't be mandatory limits on their hours, says Dr. Kaif Pardhan, vice-president of the Canadian Association of Internes and Residents.
"While surgical residents are concerned about burnout, many of them feel that cutting back on work hours isn't the solution and does, in fact, limit their education," Pardhan explains.
Dr. Kevin Imrie, co-chair of the Pan-Canadian Consensus on Resident Duty Hours and President-Elect of the Royal College of Physicians and Surgeons of Canada, says a one-size-fits-all hour limit doesn't work, since some medical specialists – such as surgeons – can only be trained at odd hours because of hospital work schedules. (Courtesy Kevin Imrie)
American residents have had work-hour limits since as early as 2003. The United States Accreditation Council for Graduate Medical Education now requires their shifts to be shorter than 16 hours in their first year of residency and shorter than 24 hours in later years. Medical residents in the U.S. are not allowed to work more than 80 hours a week.
Quebec adopted similar 16-hour consecutive work-hour restrictions in 2012, but no weekly limit.
Resident work hours aren't strictly limited elsewhere in Canada, though there is a general rule that residents shouldn't work longer than roughly 24 hours in a row. But since the rules aren't audited or mandated by law — as they are in the U.S. and Quebec — residents can work longer if they choose.
Complaints about overwork are raised by residents through self-reporting instead, says Dr. Kevin Imrie, co-chair of the Pan-Canadian Consensus on Resident Duty Hours and President-Elect of the Royal College of Physicians and Surgeons of Canada.
Imrie agrees that working 24 or more consecutive hours without sleep should be avoided. But, a one-size-fits-all work-hour limit isn't a solution, Imrie says, since some specialists – such as surgeons – can only be trained at odd hours.
"It matters how many times surgical residents do a certain operation, many of which occur in the middle of the night," Imrie says.
Daily vs. weekly caps
The study published in Annals of Surgery in March, which focused on surgical residents, came after the Canadian Medical Association, the Royal College of Physicians and Surgeons of Canada, and medical resident associations and hospitals met in 2012 to decide whether to limit resident work hours across Canada.
The study did find that capping the workweek at 80 hours improved residents' own wellness. Residents reported slightly lower rates of fatigue and a better quality of life.
But when it came to 16- and 24-hour work limits, there was no improvement in resident wellness. In fact, many residents reported worsening of their quality of life and education.
In the U.S., where work-hour restrictions are in full force, advocates like Dr. Joanne Conroy, the Chief Healthcare Officer for the Association of American Medical Colleges, says, "we should be able to train capable doctors in an 80-hour work week.
'The jury's still out on 16- and 24- hour consecutive work hour restrictions, but limiting to 80 hours a week really improves quality of life for medical residents.'- Dr. Joanne Conroy, Association of American Medical Colleges
"The jury's still out on 16- and 24- hour consecutive work hour restrictions, but limiting to 80 hours a week really improves quality of life for medical residents," she adds.
Convoy suggests that surgical training programs can find alternative methods of teaching surgeons, like the use of simulators that would decrease the time required in the actual operating room.
Dr. Thomas Nasca, the Chief Executive Offer of the Accreditation Council for Graduate Medical Education in the U.S., says limits on resident work hours are required, but agrees there are concerns about the current consecutive work-hour restrictions.
Two major studies that hope to provide conclusive answers to the work-hour debate are now underway in the U.S, according to Nasca.
In the meantime, instead of cutting work hours for Canadian medical residents outside of Quebec, says Imrie, hospitals will find other ways to reduce their fatigue.
One idea on the table is ensuring that residents get uninterrupted sleep by limiting the number of times they are called out of bed for non-urgent issues.
There will be an increasing push to use other health professionals, like nurse practitioners and physician assistants, to help reduce the workload for residents, Imrie says.
Residency programs are also looking into competency-based training, where trainees would take as long as they need to learn a medical skill and then move on. But this could mean additional years of training on top of an already arduous five-year residency.
Going forward, the Pan-Canadian Consensus team will be looking more closely at how training programs and hospitals manage resident fatigue, with the hope of making it a major part of residency program evaluations.
At the end of the day, "there's just no substitute for experience in the operating room," Rutka says.
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