Shift work surgery: Loss of continuity or sensible balance of responsibility?

The Advocacy and Issues Committee of the Resident and Associate Society of the American College of Surgeons (RAS-ACS) hosts the annual RAS Symposium at the Clinical Congress. During this session, a panel discusses an issue affecting surgeons and surgical residents. The 2019 symposium will explore the topic of shift work surgery and whether this trend erodes continuity of patient care or allows residents to achieve a sensible balance of responsibility. The RAS Symposium will take place Sunday, October 27, at the Moscone Center, San Francisco, CA.

Introduction

Surgical residency training programs have implemented dynamic scheduling and curricula changes in recent decades. Perhaps the most remarkable of those changes was the move by the Accreditation Council for Graduate Medical Education (ACGME) in 2003 to standardize the 80-hour workweek.¹ These duty-hour restrictions were implemented in response to concerns about physician fatigue, medical errors, communication-related errors, and physician burnout.² After implementation of these standards, researchers involved in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial suggested that tractable work hours better promoted patient continuity of care and resident education without associated negative patient outcomes.³ Even so, the FIRST trial highlighted concerns regarding work-life integration. Ultimately, this trial has energized a debate over how duty-hour restrictions have changed not only resident physician scheduling and patient outcomes but also surgical culture.

The historical model for surgical training included unrestricted hours. Residents stayed at the hospital to finish cases and start new ones, attended to patients throughout the entire perioperative period, and worked home-call shifts for nights and weekends without designated time off. However, duty-hour restrictions spawned structural changes toward a shift work model, with 12-hour schedules, designated days off, and limitations on hours within call shifts. This arrangement has been incorporated into several surgical specialties, including trauma and acute care surgery. Other surgical specialties have initiated shift work arrangements too, with dedicated coverage to prevent 24/7 call responsibilities for an individual surgeon.

This shift work model has been so widely adopted, initially because of the ACGME mandate, that it has caused a cultural shift, with movement toward heightened awareness of physician wellness and burnout; efforts to improve communication, particularly during handoffs; and the establishment of reasonable limitations to arduous schedules. These trends have had a positive effect on the surgical culture but have also ignited concern that this shift work approach has ushered in a change in surgeon mentality—namely, that surgeons undervalue continuity of care and patient ownership—as well as hands-on educational opportunities.

This concern has led to debate within the profession regarding the optimal way to implement surgical shifts or whether surgery should avoid moving toward shift work entirely. The 2019 RAS Symposium participants will debate whether shift work surgery should be encouraged to foster a sensible balance of responsibility and promote surgeon wellness or whether it should be discouraged, as it reduces continuity of patient care and exposure to educational opportunities.

This article outlines the history of shift work surgery, explores the possibility that this model acts as a detriment to patient care and resident education, and examines whether it functions as an appropriate response to work-hour restrictions with improved resident wellness and a sensible balance of patient responsibility.

The transition to shift work

Scheduled shifts were first introduced in the 1980s in the form of night float teams in obstetrics/gynecology residencies, as a result of the Council on Resident Education in Obstetrics and Gynecology’s focus on reducing hours spent in the hospital.⁴ A transition to shift work scheduling came in the wake of the work-hour restriction laws instituted in the state of New York after the March 1984 death of Libby Zion, an 18-year-old college student who tragically died in the emergency room while in the care of overworked residents.⁵ In logical fashion, the ACGME imposed similar work-hour restrictions on accredited residencies nationwide.⁶ The night float system subsequently became widespread across residency programs to accommodate these new regulations.

The demands for work-hour restrictions led to debate concerning the effect of shift work on resident education. Initial reports examining resident education in the night float system suggested residents on night float interact less with faculty, receive less feedback, are absent from daytime didactic sessions, and have less operative experience.^7,8 Despite these potential drawbacks, the night float system persisted and programs have made adjustments to ensure that educational quality is maintained.⁹ The benefits to patients and residents with a night float system have been reported.¹⁰ In a 2019 study of more than 7,000 surgical patients comparing night float with overnight on-call residents, Yu and colleagues found decreased postoperative bleeding and shorter response time to emergent consultations in the night float system.¹¹

Goldstein and colleagues reported results of a resident survey after implementation of a night float system at a New York general surgery program. Residents reported decreased fatigue, better resident-nurse communication, more time for sleep at home, and increased time spent on independent study.¹² Despite these benefits, faculty in this same study reported decreased continuity of care as a result of the night float system. This concern has been echoed in other studies, highlighting concern about the shift work model and its link to a decreased sense of patient ownership.^13,14

The debate around continuity of care, communication errors in sign-out, decreased physician fatigue, and improved physician wellness in the context of the night float system has regained momentum in the shift work era. Shift work surgery is virtually synonymous with acute care surgery, the specialty that has most widely adopted this structure.¹⁵ This construct allows a dedicated attending to be available for 12- or 24-hour shifts, free of clinic and elective caseloads.¹⁶ This structure was created to improve health care outcomes, maximize surgical resources, and increase cost savings for hospitals, but it also has attracted more physicians to surgery as a result of the lifestyle benefits derived from a more controlled schedule and nighttime responsibilities.^16-19 The shift work structure has been compared with previous call models and the literature reports decreased time to the operating room (OR), decreased complication rates, and decreased length of stay for common acute care pathologies (such as appendicitis and cholecystitis) because an acute care surgeon is in-house on shifts.^16,18 However, recent literature has highlighted the concern within this model about physician fatigue and chronic sleep deprivation, which may result from demanding shifts and duties that often extend beyond designated hours.^20,21 Furthermore, some surgeons have voiced concern about continuity of care and communication within this fragmented model of shift work, as many acute care surgery models still lack formal sign-out procedures.¹⁹ Other specialties have adopted shift work and have thereby expanded the discourse regarding the pros and cons of this structure.

Shift work surgery: Loss of continuity

Shift work mentality can be seen as a threat to the professional tenets that define the core values of a surgeon. These values are grounded in the concept of patient care ownership, which translates into the primary surgeon being available and responsible for all events and decisions in the perioperative care of the patient at all times. Patient care ownership has been described as “a central tenet of surgical professionalism dating back decades and is fundamental when facing critical patient care decisions.”²²

The ACGME, which established the standards for duty-hour compliance, has also recognized the importance of continuity of care, stating that “continuity of care must take precedence—without regard to the time of day, day of the week, number of hours already worked, or on-call schedules.”²³ The ability to provide continuity of care can be beneficial to both the patient and the surgical trainees.^24-26 Many surgeons agree that signing out a patient to a different provider is a poor substitute for knowing the important details of that patient’s clinical course and can lead to communication errors.²⁷ Patient management by the same individual ensures a thorough understanding of all nuances of their perioperative course. The resident providing this continuous care also benefits from opportunities to see how a patient’s disease evolves, which can be an invaluable educational experience.

Teman and colleagues surveyed 239 attending surgeons and found that 14 percent of the respondents cited shift work mentality, decreased patient ownership, and sense of responsibility as factors preventing residents from achieving graduated autonomy in the OR.²⁸ Despite duty-hour restrictions, evidence has shown that surgical residents often continue to work after their designated shift as a result of beliefs about patient ownership and professionalism,²⁹ indicating a reluctance to succumb to a shift work mentality.

In parallel to work-hour restrictions affecting the structure of surgical residency, changes at the level of surgical staffing have occurred as well. The acute care surgery model has been structured as shift work since its inception, but shift work may be ill-suited for training in other surgical specialties. Most acute care surgery cases involve new patients who are receiving care for a new urgent or emergent surgical condition. Surgeons who provide elective operations historically have been responsible for continuous management of their patients. This practice ensures that the surgeon who evaluated the patient in the clinic and performed the initial procedure also is the one who makes decisions regarding postoperative care. An important, established relationship forms between the surgeon and the patient, especially in surgical oncology—one that can span months to years. To many surgeons, this relationship justifies the expectation that a patient’s surgeon continues to be responsible for any surgical issues that arise.

Although structured shifts exist across resident training programs, and different variations of night and weekend coverage are increasingly common outside the realm of the acute care surgery model, there is evidence that many residents and attendings alike often modify or work outside of the hours of their scheduled shifts.³⁰ Unfortunately, any shift work arrangement opens the door for adoption of a shift work mentality, especially as the culture of previous surgical generations begins to fade. If a shift work mentality becomes more widely adopted with these changes, it could lead to decreased quality of patient care, professionalism, and resident education.

Shift work surgery: Sensible balance of responsibility

While concerns about shift work mentality have emerged in recent years, that discussion detracts focus from the motivating factor for adoption of shift work surgery. Surgical trainees are at an ethical impasse where they must choose between discontinuity in patient care and personal exhaustion. Neither option is innocuous, so many residents attempt to resolve this dilemma by fabricating their duty hours or finding loopholes in documentation.³¹ Despite surpassing the 80-hour limit, some residents will continue to work even after leaving the hospital or on designated days off by charting and tracking patients via the electronic health record.³⁰ Many modern trainees are so stalwart in their commitment to patient care at the sacrifice of their well-being that they unfalteringly attend work when physically ill.³²

Shift work has emerged in part as a result of surgeon concerns about work-life integration, including time for sleep and recovery.^33,34 Rest is crucial for humans, particularly those individuals charged with caring for the lives of others. For example, the Federal Aviation Administration limits the time for a single pilot voyage to eight hours.³⁵ Likewise, the Federal Motor Carrier Safety Administration regulates driving time to no more than 11 hours per day and 60 hours per week.³⁶ The American Academy of Sleep Medicine has gone as far as to support drowsy-driving legislation, which states that a person who has been awake for more than 22 of the previous 24 hours is functionally impaired by sleep deprivation.³⁷ Working while exhausted is hazardous, so why are surgeons expected to perform without time to recuperate?

With respect to surgical trainees, sleep deficit negatively affects monotonous tasks and can jeopardize safety when residents drive home after shifts.³⁸ Residents have been shown to make more technical errors and take longer to complete simulated laparoscopic tasks after a night on call.³⁶ Literature demonstrating the need for rest among attending surgeons has been published. Rothschild and colleagues demonstrated a 1.7-fold increased rate of complications in postnighttime cases among attendings who had six or less hours of sleep opportunity compared with attendings whose sleep opportunity exceeded six hours.³⁹ Patient safety is of paramount importance, such that the Sleep Research Society has drafted legislation requiring that surgeons who have been awake for 22 of the previous 24 hours inform their patients of the safety impact of sleep deprivation before performing any operation.³⁷

Shift work may have a negative undertone to many seasoned surgeons, but as Coleman and colleagues have reported, lifestyle is an important factor in the modern-day trainee’s choice of specialty.³⁴ Similarly, Santry and colleagues reported that among 18 prominent acute care surgery leaders, key reported benefits of this specialty were improved job satisfaction, increased operative volume, and a better lifestyle.¹⁹ The acute care surgery shift work model offers pager-free periods yet still entails responsibilities on certain nights and weekends. This practice pattern facilitates rest and family time, and promotes continued enthusiasm for the profession.³⁴ This model also facilitates career advancement, allowing unhindered time for research, quality improvement endeavors, and teaching.

Acute care surgeons are not the only health care professionals benefitting from the shift work approach. Surgical hospitalists, often referred to as surgicalists, have attempted to assuage the lack of surgical coverage that afflicts 75 percent of U.S. emergency departments.^40,41 Maa and colleagues studied the impact of a surgical hospitalist service at the University of California San Francisco Medical Center, which employed three full-time board-certified general surgeons who staffed the service on a rotating weekly basis.⁴⁰ The surgeons had a minimal number of elective procedures or clinic hours during their service week and were responsible for rounding daily, supervising residents, and seeing all emergency department and inpatient consults. By having more time as a result of not being continuously met with elective cases, administrative duties, and clinic patients, these surgeons could appropriately bill for services rendered during a patient’s hospitalization. By maximizing documentation and coding, the hospital’s revenue generation from surgical services increased 415 percent. Furthermore, from the time an emergency room physician placed a consult, the patient was seen by a surgicalist within 20 minutes rather than several hours, which was common prior to shift work implementation.⁴⁰

Similar shift work delivery systems have led to greater satisfaction among referring physicians and hospitals,^19,34 increased resident supervision,⁴⁰ and decreased hospital costs and lengths of stay.⁴² Many training programs see the benefit of shift work and have implemented night float systems, and as Kohlbrenner and colleagues have demonstrated, this approach leads to better compliance with duty-hour restrictions, improved resident education, and higher quality of life.⁴³ Shift work surgery will always have its critics, but as sleep medicine physician Michael Farquhar, MD, stated, “There is no shame in being ordinary, in acknowledging we have the same human needs as our patients for comfort, for rest, and for sleep. Without them, we cannot function. The shame is in allowing systems to depend on us routinely being extraordinary because ultimately, we—and they—will fail.”⁴⁴

Conclusion

In the era following work-hour restrictions, shift work surgery has become increasingly adopted within the acute care surgery model and other surgical specialties. The resulting debate centers on patient outcomes, resident physician wellness and education, and the surgical culture at large. Commitment, accountability, and consistent quality remain cornerstones of optimal patient care; however, the ability of any human being to deliver on these qualities at all hours has raised concerns regarding dilution of these traits due to physician fatigue and decreased quality of personal life. The shift work model provides an alternative pathway whereby surgeons are relieved by colleagues to allow a revitalized workforce. At the same time, increased transitions between health care professionals prompt concern about decreased continuity of care predisposing to increased medical errors and decreased perception of ownership.

The RAS Symposium at the ACS Clinical Congress will explore the topic of shift work surgery with a debate on whether this model represents a loss of continuity in patient care or offers a sensible balance of responsibility. Join other residents, Associate Fellows, and leaders in the field at the symposium to discuss the optimal approach to providing continuous, uncompromised patient care and resident education.

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