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

General surgery is a tough and demanding profession that attracts particular individuals with an “unwritten but understood code of rules, norms, and expectations.”¹ Training in a surgical residency is a rigorous and long process that requires substantial commitment, dedication, and determination; however, the required hard work, long work hours, and the need to deal with their patients’ life and death situations create personal sacrifices that may lead to burnout and other negative repercussions on individual well-being.¹

Effect of work-hour restrictions

The July 2003 implementation of the Accreditation Council for Graduate Medical Education’s resident work-hour restrictions led to general surgery training reforms designed to reduce the adverse physical and mental health effects on residents and to reduce medical error resulting from sleep deprivation.^2-5 Several studies have analyzed the different aspects of how work-hour limitations have affected American Board of Surgery In-Training Examination (ABSITE) performance, resident quality of life, burnout, quality of patient care, patient morbidity and mortality, continuity of care, and time spent in the operating room.^2-7 These studies have found that ABSITE performance, resident quality of life, and burnout have significantly improved, and a less significant improvement or no change was revealed in quality of patient care, morbidity and mortality, and operative experience. However, researchers did find a decrease in continuity and coordination of care, raising concerns that residents were developing a shift work mentality, leading to a decrease in residents’ responsibility—a deviation from the patient-focused culture in the surgical profession.²

Despite all the concerns that have emerged with regard to the duty-hour limits and their effect on surgical resident competency and readiness for independent practice, no studies have shown any worsening of quality patient care. In fact, this shift work model could correlate with higher prevalence of newly board-certified surgeons choosing to join surgical groups instead of going into independent practice, which could lead to a more robust surgical workforce. U.S. surgeons in group practices are less likely to experience work-home conflicts. A cross-sectional study found that work-home conflicts is associated with burnout, symptoms of depression, problematic alcohol abuse, and career dissatisfaction and is more prevalent among surgeons who had fewer years in practice, longer work hours per week, and more frequent overnight calls.⁸ Some other independent factors associated with work-home conflicts were gender and having children, with women surgeons and surgeon parents (regardless of gender) at greater risk.

As a benefit of the shift work model, junior surgeons will be joining senior surgeons to decrease their weekly clinical work hours and subsequently reduce their work-home conflicts and maintain work-life balance. A systemic review of surgeon burnout found that nine out of 10 studies reported increased risk with the number of hours worked, and seven out of 10 studies reported an increased risk of work-life imbalances.⁹

Applications in acute care surgery and hospitalist programs

Two successful surgical disciplines have successfully implemented the shift work model. One is acute care surgery, which is most commonly staffed by trauma surgeons in academic settings in response to the decreasing interest in emergency call coverage among general surgeons, who are becoming increasingly more specialized.¹⁰ An acute care surgery model that started at Loma University Medical Center, Loma Linda, CA, in 2010 combined trauma and emergency general surgery into a 12-hour, in-house service, which improved patient outcomes.¹¹ In 2012, the institution performed a retrospective study comparing the acute care surgical model with the traditional surgical care model. This study showed that the acute care model resulted in lower costs and improved quality of care for patients who underwent appendectomies and cholecystectomies.¹¹ Similarly, a Level I trauma center in Texas reported struggling with yearly increases in workload in trauma, critical care, and emergency general surgery call until a redesigned model was introduced that comprised a team of six surgeons and a 12-hour shift for 14 out of 28 days.¹² The results were two weekends off per month; less disruption of circadian rhythm; protected time for research, education, and administrative work; and improved efficiency at the hospital by the cohesive team of surgeons. This new, redesigned 12-hour shift has been referred to as “surgeon- and patient-friendly.”¹³

Surgical hospitalists—surgeons with “nearly exclusive inpatient practice”—also follow the shift work model.¹⁴ This profession came about to address the shortage of surgeons in hospitals and the burden of emergency department (ED) call for general surgeons.^10,12 The University of California San Francisco (UCSF) introduced this program in July 2005, and some results of its prospective study on patient outcome showed shorter ED length of stay and improved timeliness of care.¹² Another significant outcome was in hospital revenue, with a 24-fold increase in the first year of the program, resulting from a 190 percent increase in requested consults from ED and inpatient wards. One of UCSF’s surgical hospitalists reports that this model is a “far cry” from anything he would have dreamed when he started surgery years ago and that “it is the wave of the future.”⁹

In conclusion, it is important to remember that surgeons are human beings with their own personal lives who, at the same time, care for their patients. But the increase in health care demand makes it challenging to find a balance. As more general surgeons become more specialized, the shift work model will play a major role in addressing the shortage of general surgeons who take ED calls. The benefits of the shift work model, in comparison with the traditional culture of surgery, seem to outweigh the lack of continuity of patient care in surgical practice. Moreover, as the trend of physician shortages continues, the future leaders in the field of surgery foresee a potential new adaptation with a new practice model to better balance health care challenges, patient care, and physician well-being. For now, shift work surgery works best and should be viewed as a sensible balance of responsibility.

References

1. Balch CM, Freischlag JA, Shanafelt TD. Stress and burnout among surgeons—understanding and managing the syndrome and avoiding the adverse consequences. Arch Surg. 2009;144(4):371-376.
2. Hutter MM, Kellogg KC, Ferguson CM, Abbott WM, Warshaw AL. The impact of the 80-hour resident workweek on surgical residents and attending surgeons. Ann Surg. 2006;243(6):864-875.
3. Durkin ET, McDonald R, Munoz A, Mahvi D. The impact of work hour restrictions on surgical resident education. J Surg Educ. 2008;65(1):54-60.
4. Antiel RM, Reed DA, Van Arendonk KJ, et al. Effects of duty hour restrictions on core competencies, education, quality of life, and burnout among general surgery interns. JAMA Surg. 2013;148(5):448-455.
5. Fletcher KE, Reed DA, Arora VM. Patient safety, resident education and resident well-being following implementation of the 2003 ACGME duty hour rules. J Gen Intern Med. 2011;26(8):907-919.
6. Rajaram R, Chung JW, Jones AT, et al. Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance. JAMA. 2014;312(22):2374-2384.
7. Misra S, Schertz P. Resident wellness—developing good habits for long term success. HCMA Bulletin. 2018;64(3):26-27.
8. Liselotte DN, Shanafelt TD, Balch CM, et al. Relationship between work-home conflicts and burnout among American surgeons—a comparison by sex. Arch Surg. 2011;46(2):211-217.
9. Dimou FM, Eckelbarger D, Riall TS. Surgeon burnout: A systematic review. J Am Coll Surg. 2016;222(6):1230-1239.
10. Skeptical Scalpel. New fields in general surgery and the rise of the surgical hospitalist. KevinMD.com. Available at: www.kevinmd.com/blog/2011/06/fields-general-surgery-rise-surgical-hospitalist.html. Accessed September 20, 2019.
11. Cubas RF, Gómez NR, Rodriguez S, et al. Outcomes in the management of appendicitis and cholecystitis in the setting of a new acute care surgery service model: Impact on timing and cost. J Am Coll Surg. 2012; 215(5):715-721. Accessed October 15, 2019.
12. Maa J, Carter JT, Gosnell JE, Wachter R, Harris HW. The surgical hospitalist: A new model for emergency surgical care. J Am Coll Surg. 2007;205(5):704-711.
13. 1 Dissanaike S. Walking the walk on reducing surgeon burnout. General Surgery News. Available at: www.generalsurgerynews.com/Opinions-and-Letters/Article/12-18/Walking-the-Walk-on-Reducing-Surgeon-Burnout/53553. Accessed September 20, 2019.
14. Nelson J. A surgical surge. The Hospitalist. Available at: www.the-hospitalist.org/hospitalist/article/123475/surgical-surge. Accessed September 20, 2019.