Surgery Blog for Surgeons

Work load in surgical education - impact on education and healthcare

The introduction of the 80-hours week for the residents in the USA brought a lot of unhappy faces in the faculty members. Ever since then the residents have to listen to even more "what-do-you-know" and "when-I-was-a-resident" stories on a daily basis. The generation conflict is remarkably expressed in these conversations and it is caused solely by the attending physicians. They urge the residents to protest against these rules arguing that working more than 80 hours per week is essential for a sufficient education.

The recent proposal for further reducing the work load to 60 hours per week led to a frank outrage among the physicians in charge. I don't know to what percentage these colleagues are concerned about education or future patient care on the one hand, and possible envy because the current residents have to suffer less than they did in the past on the other hand. Recently I was involved in a discussion about the upcoming changes in the residents work load and after that I just looked at the vastly available data about diverse topics which are a necessary part of those kind of discussions.
I would like to take examples from the situation in the General Surgery Residency in the United States and Germany as I am familiar with these systems. For this purpose I will discuss several arguments frequently brought by proposers of the "unlimited" (or "residential") working.

Thesis: the more you work in the hospital, the more you will learn and the more skills you would acquire.

There are several issues with this one.
Residents are actively (and in some occasions more than any other group) involved in patient care. Expecting that a person would work for more than 24 hours and be able to provide the same quality of patient care would assume that we should be allowed also to come to work drunk. There is enough data showing that being awake for 24 hours would make your reactions and thinking comparable to a person who drank alcohol up to 1‰ blood content.
Most surgeons tend to ignore this data. And this is markedly unprofessional and non-scientific!
Instead, couple of papers were published, apparently showing no significant increase in the complication rate when surgeries were performed by non-rested surgeons. I will not discuss the quality of these studies; if the same criteria would be used to critically review these publications as they are used to discuss articles in journal clubs, those kind of pseudo-science would not make it to a discussion at all. And there is a simple question which everyone should think about: would you let your mother be operated by someone who did not sleep for 20-30 hours?
I know surgeons who caused almost deadly motor vehicle accidents on the way home after working for that long. And I still consider driving a car way easier than operating on a patient.

Being on call and then staying for the next day, and the other day being then at 5:30am on the floor for the rounds (and this possibly q2/q3) would simply mean that there would be no other life: no time for any reading (incl. medical), no time for a proper communication, nothing!
I did work under those kind of circumstances and it did not improve my surgical knowledge and/or skills. My honest opinion is that de-socializing of the residents will not make them better doctors.

Thesis: continuity of care is not provided when residents go home.

Continuity of care should be a goal if it would lead to improved care only. Worldwide most ICU staff (incl. physicians) work in shifts. And this is exactly the opposite of "continuity of care". ICU's are not really a good place to neglect quality of patient care. Obviously they still function and have success.
The ideal situation to preserve continuity of care is to not stop working. If we should draw a line, it should not be beyond the exhaustion of the involved stuff.

Thesis: The health care is not payable if we can not rely on cheap working stuff.

It is!
But it requires efficiency. Bloated stuff, unlimited breaks and increasing paperwork are not part of it though.

Thesis: we give the most money for health care and this is the way we receive the best one.

Yes, the USA gives out the most money for health care but it does not achieve the best results this way.
What does the data say? (On the website of the WHO various data is published on a regular basis.)

United States achieve good results among the OECD countries. Surely they have good success in some areas whereas in others they don't. The overall impression is though that the Americans get less for a spent $1 for health care than anyone else in any OECD country. The Americans claim also to work the most which is relative since under "work" they include the multiple breaks, lunches, talks, and endless rounds (involving not uncommonly tens of people). I know that the people in the USA consider this style of working normal. But this means also that they would not understand how a Germany doctor could go home at 5pm after having worked since 7am in a way that there was no time even for a snack: no talks, no breaks, nothing, nada, just work! And this every day.

Americans tend to measure motivation on the time spent at work regardless of the actual work done. On the other hand I know centers in Germany where staying late at work is considered to be a sign of lack of efficiency. Not exceeding 40-50 hours per week of work was part of the law in the Scandinavian countries for many years and just to come in Germany.

The WHO data shows that quality in health care is not function of the work (time) load per person. Excellent health care can be obviously achieved even when providers are allowed to have also time for something else than work.

There are many other factors which led to the high acceptance of working as living in the hospital in the past. These factors are not relevant any more. The world has changed and will keep changing. The current generation of residents should have this in mind when they - then as attending surgeons - would start moaning about the way their residents will work in the future. The quality of health care and/or education will not deteriorate because of that. At least not because of that!