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Academic Medicine:
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The Effect of Limiting Residents’ Work Hours on Their Surgical Training: A Canadian Perspective

Romanchuk, Ken MD

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Author Information

Dr. Romanchuk is professor of ophthalmology, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada.

Correspondence and requests for reprints should be addressed to Dr. Romanchuk, Eye Centre, Saskatoon City Hospital, 701 Queen Street, Saskatoon, Saskatchewan, Canada S7K 0M7; e-mail: 〈ken.romanchuk@saskatoonhealthregion.ca〉.

For articles on related topics, see pp. 379–380, 381–383, 394–406, 407–416, and 447–452.

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Abstract

Restrictions in residents’ work hours have been in place in Canada for roughly a decade, having been negotiated rather than imposed. The changes in residents’ schedules that resulted are roughly equivalent to the limitation of 80 duty hours per week in the United States. When work-hours restrictions began, surgery faculty were worried that residents’ experience would be compromised. But these fears have not materialized. Why? The author maintains there are many reasons. (1) Most surgical procedures are now faster, and lengthy inpatient care has diminished, all of which saves time. (2) Formerly difficult or risky procedures are now performed more frequently and safely, which increases residents’ education about difficult conditions. (3) A variety of resources (e.g., skills-transfer courses, surgical simulators, etc.) are now available for residents to learn and evolve surgical techniques, and residents take advantage of these resources, being highly motivated to learn the best in the time available to them. (4) There have been positive changes in residents’ education that have helped them become more efficient learners than before, with improved resources and skills for faster access to information. The author maintains that in his present surgery residency program, the residents still work extremely hard but are more protected from the unending demands for patient care. They have more time for orderly study and greater opportunities to develop skills other than technical ones. They are in a happier work setting, which the author strongly believes facilitates improved patient care.

When I started my three-year residency in ophthalmology in 1976, nominally I was on call “1-in-3,” which was defined as being on call for the entire first year. There were no evenings off, no nights off, no weekends off, no holidays off, and no time off for meetings, except for two weeks (or was it three?) of vacation.

So 24 hours a day, seven days a week, for the entire first year (less vacation), I was responsible for attending daily morning ward rounds where every patient had their eyes examined, admitting and providing hospital care for the usual eight to 14 patients on the ward, examining patients in the daytime clinics of one of the attending staff, assessing all incoming eye emergencies, giving intravenous injections in the clinic for fluorescein angiography etc. I was allowed to go home in the evening (after admissions to the ward were completed) but was expected to return from home to respond to all calls for emergency assessment. The “reward” during the first year was that I was first assistant at all elective strabismus surgeries, thereby accumulating considerable technical prowess in this field somewhat before I understood exactly why surgery was being performed.

The attending staff didn't have any call roster for emergencies, so it was up to me to find one if the occasion arose! Ah, those were the days when residents were residents! We learned fast and tough.

Over time, residency associations formed and gained legal status to negotiate wages, work hours, and benefits for the residents in all ten provinces, with much angst as to whether it was proper for professionals to do so—after all, we were MDs!

Today there are seven residency associations in Canada, with each conducting separate negotiations with each province or region. Generally in-house call is limited to “1-in-4” (i.e., being physically in the hospital for one 24-hour period in four days). Home call is “1-in-3” (i.e., responding to call from home for one 24-hour period in three days). There are provisions for relief from clinical duties the day after this 24-hour period of call, taking into account proper transfer of patient care. There is some leeway to allow call to be more frequent to overcome scheduling difficulties, and for weekends. I think this works out roughly equivalent to the limitation of 80 duty hours per week in the United States.

Restrictions in work hours have been in place in Canada for roughly a decade. Most surgical specialties require five years of training, but some require more.

Faculty were worried that residents’ experience would be compromised, leading to poorer success in qualifying examinations, poorer technical skills at the end of a surgical residency, increasing number of patient complaints regarding surgical outcome, and increasing malpractice actions regarding surgical outcomes once in independent practice. But these fears did not materialize, as least as far as we can track through qualifying exams and regular accreditation visits administered for all specialties by one national organization (The Royal College of Physicians and Surgeons of Canada); quality-assurance programs in our hospitals; complaints regarding surgical outcome to our provincial licensing agencies (that are now quite proactive in bringing deficiencies to light); and regular reports of specific trends in medicolegal actions from our national medical protective association (that provides malpractice insurance and medicolegal advice for most physicians in Canada). Most problems that arise from the later two involve poor communication.

Why didn't these anticipated problems arise for surgery? Probably for many reasons.

Due to advances in technique, equipment and operating room efficiency, most surgical procedures are now faster, and a greater number can be performed in the same period of time. The need for lengthy inpatient care has diminished. Not only did patients benefit, but residents themselves have had more surgical experience in a set amount of time.

Procedures once unimaginable, too difficult, or too risky are performed more frequently and safely than in years gone by, actually increasing residents’ education about difficult conditions and making them think more critically about remaining challenges.

Surgical techniques change fairly rapidly, and surgeons continuously evolve their techniques. For those readers who are surgeons, ask yourself if you treat a specific condition exactly the same now as you did five years ago? It's not very often that any one technique outlasts a career anymore! Excellent skills-transfer courses are available locally and through national physician organizations, many of which are U.S. organizations. Surgical simulators are evolving, and practice labs are available if one makes the effort. Residents take advantage of these learning resources during their training, being highly motivated to learn the best in the time available to them, and continue to evolve once they graduate.

Role modeling is important. Most of us realize our own limitations, and seek assistance when necessary. Residents observe and emulate this attitude.

There has been a shift in educational standards. Competence is no longer determined by the raw number of procedures performed and patients examined. Rather, there are predetermined educational goals and objectives, with forthright evaluation of residents based on these. The role of the medical expert is still paramount, but communication, collaboration, scholarly, professional, managerial and advocacy roles are mentored. Residents tend to be more efficient learners than previously, with improved resources and skills for faster access to information.

When I look at our residency program 23 years later, the residents still work very, very hard, but are definitely more protected from the unending demands for patient care. They have more time for orderly study and greater opportunities for developing skills other than just technical ones. Overall, they are in a happier work setting, and I strongly believe that this facilitates overall improved patient care.

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