In response to current national discussions of the advisability of limiting resident work hours, the American College of Surgeons wishes to make a statement that emphasizes the important and somewhat unique aspects of residency training in surgery.
The debate concerning resident working hours arose from the adverse outcome of a patient admitted to a medical service of a major teaching hospital. In this case, the issues of responsibility for and supervision of the patient's care, by both the resident and attending staff, have been questioned. Unfortunately, these central issues have been submerged into a discussion of fatigue and length of resident working hours, even though analysis of the experiences with the patient concerned indicate that fatigue was not a major factor influencing the tragic outcome. It should be emphasized that all of the current discussion of house staff hours evolved from one case on a medical service, not from a detailed study of fatigue among house staff at an entire hospital over a period of time.
The Accreditation Council for Graduate Medical Education (ACGME) has long emphasized that the primary purpose of the residency is to educate physicians and surgeons. It has established excellent general guidelines on the scope and content of residency programs. The American College of Surgeons supports strongly the premise that medical education must involve the provision of exemplary and properly supervised clinical care. The patterns of behavior learned in residency will persist throughout a physician's professional life.
The College strongly disagrees that specific hours (for example, 84 hours per week) can be defined for each surgical specialty. Similar hour restraints have never been applied, or even discussed, to either attending or practicing surgeons. Thus it seems illogical to make specific time-work recommendations without considering the effect on the educational opportunity and experience for those in the residency phase of their career.
Basic principles of surgical education
Several parts of the system of surgical education merit special emphasis:
- Continuity of Care. The hallmark of surgical care has long been the commitment of surgeons to be available to their patients throughout the surgical experience. If such availability is not possible, the patient must be informed and alternate arrangements made. This crucial commitment to continuity of care involves the development of an attitude that is best learned from supervising surgeons who serve as proper role models. Continuity of care must take precedence over other aspects of the resident's activities.
There are several reasons that continuity of care is the most important principle in surgical education. Decision-making is best learned and taught by working with a critically ill patient and serially observing response to therapy for complex problems. This, of course, mandates that the surgical resident be fully familiar with the patient and all pertinent data. Lack of familiarity with a patient, not fatigue, is the major cause of errors of judgment. This is a crucial point because undue emphasis on working hours that disrupt continuity of care could easily harm, rather than improve, patient care.
- Supervision. The care delivered by surgical residents at all levels must be supervised. Although senior residents require less direction than junior residents, they must also be supervised. A surgical residency program has an established chain of command that emphasizes graded authority and increasing responsibility as experience is gained. Deciding the appropriate degree of delegation of responsibility is based on the attending surgeon's knowledge of each resident's skills and ability, usually gained by direct observation. The attending surgeon is ultimately responsible for a patient's care.
- Working patterns. The primary goals of residency training in surgery are education and continuity of care. Work schedules should be set to serve those ends. The working hours themselves should not be a principal concern in the design of a residency program. Different specialties require different working hours and patterns. Work in an Emergency Department, for example, is steady and does not involve continuity of care, so it can be more rigidly scheduled. Also, some surgical specialties are more time intensive than others.
It is most important to make a clear distinction between on-call time, both in the hospital and at home, and actual hours worked. The ratio of the actual hours worked and on-call may vary with the level of residency. A junior resident may have a ratio approaching unity while the senior resident may have a ratio of 0.5. The varying time requirements for intensive care and also in the ratio of hours worked to hours on-call are both important facts that preclude a set pattern of established hours, either within a specialty or between specialties.
- Inappropriate duties. Perhaps most important, support services must be adequate so that residents do not spend an inordinate amount of time, particularly during on-call hours at night and on weekends, in non-educational activities that could be easily performed by paramedical and clerical personnel. Due both to the growth of medical technology and increasing budgetary measures, residents have been used increasingly to perform medical chores unrelated to direct patient care. In studies in some teaching hospitals, 70 to 80 percent of working hours at night have been found devoted to such work and are both unrelated to patient care and of negligible educational benefit. It should be emphasized clearly that this inappropriate use of residents' time and skills is the major reason for long working hours at night.
Residency Review Committees
The Residency Review Committees (RRCs) for each specialty have already addressed some of these considerations in their Special Requirements. The matter of supervision, hours, inappropriate duties and working conditions, however, should be reassessed by the individual RRCs. The program directors should establish an environment that is optimal for both education and for patient care, while ensuring that undue stress and fatigue among residents is avoided. The RRCs are the appropriate agencies to establish the specific guidelines for this important aspect of each residency.
Reprinted from Bulletin of the American College of Surgeons
Vol. 73, No. 8, Pages 22-23, August 1988