In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated an 80-hour workweek for all residents, averaged over a four-week period. In 2011, the ACGME mandated 16-hour duty periods for first-year residents; the following year, the province of Quebec instituted 16-hour duty periods for all residents. In 2009, the European Working Time Directive was implemented in European Union countries, which restricted residents to 48-hour workweeks, averaged over a six-month period. The stated goals of these resident duty hours (RDH) restrictions were to improve patient safety, resident well-being, and education.
In March 2012, a pan-Canadian consensus document on issues related to the RDH restrictions was released. The key findings in this document suggested that these restrictions may not have produced the anticipated improvements.1 In addition, individuals representing various surgical disciplines have expressed their concerns regarding the restrictions, stating that the impact on training time has had a negative effect on resident education and patient outcomes.2 In 2014, we confirmed these concerns with a systematic review evaluating the impact of the RDH restrictions on patient safety, resident well-being, and educational outcomes in the surgical discipline. We concluded that resident well-being had not improved following the enactment of the RDH restrictions, and the best available evidence suggested an unintended negative impact on patient and educational outcomes.3 Thus, a “one size fits all” approach to RDH restrictions may not be appropriate given the variation in training needs, diversity of practice patterns, and various competencies required across disciplines in medicine and surgery.1,4
The implementation of the RDH restrictions is one of the most significant transformations in medical and surgical education in recent history. Widespread research efforts have focused on evaluating the effects of these changes and to produce evidence of their impact.3,5–10 In the absence of definitive conclusions, hundreds of medical and surgical professionals have written to academic and professional communities to express their opinions on the complexity and implications of these changes. Over the last decade, these writings have provided forthright and important insights into the applicability and meaningfulness of findings from empirical research on the everyday lived clinical and educational experiences of physicians. When examined as a body of literature, one gains an understanding of the breadth and depth of the issues related to the impact of the RDH restrictions on clinical education and patient care over time. A large number of these opinion statements do not meet the inclusion criteria for a traditional systematic review, yet they offer critical insight into the state of affairs of the RDH restrictions in surgery. A qualitative study of this published literature is therefore warranted to provide context to the findings of our 2014 quantitative systematic review.3
The objective of this review of published opinion articles, then, was to describe various viewpoints regarding the effects of the RDH restrictions on the discipline of surgery.
We searched for non-research-based literature published between 2003 and 2015, using the following indexed databases—CINAHL, Cochrane, Embase, Medline, and Scopus—and gray literature sources. The search terms were decided by experts in surgical education (N.A.). We used variations of key words relating to RDH, graduate medical education, workload, continuity of care, patient safety, and surgical specialties to identify the most relevant literature available in the selected databases. Predetermined eligibility criteria were used to eliminate articles beyond the scope of this review (see Figure 1).
Articles were included if the focus was RDH restrictions in surgery and resident wellness, health promotion, resident safety, resident education and/or training, patient safety, medical errors, and/or heterogeneity regarding training or disciplines. Included articles were non-research-based publications (e.g., commentaries). Authors were trainees, surgeons, program directors, and professional societies. Research papers, published works that did not explicitly express an opinion, and position papers from regulatory bodies (e.g., ACGME) were excluded.
All articles were reviewed by two members of the research team (K.S.D., M.J.K.) for eligibility. Eligible articles identified through a hand search of the references in the previously identified articles were also included.
A thematic analysis was performed to collect and analyze data from the included articles.11 Starting with an inductive approach, we identified themes from each article. We then extracted contextual data from each article to aid in the framing of these themes.
Data coding and analysis
Six members of the research team (K.S.D., M.J.K., L.G., F.C.W., I.K., N.A.) reviewed a pilot sample of 10 articles to refine and establish consensus on the initial data collection process. The research team was divided into pairs; each team reviewed 20 articles and coded those sources to identify emerging themes. Five team members (K.S.D., M.J.K., L.G., I.K., N.A.) met to review all themes, categorize them, identify patterns, and develop a preliminary coding framework to guide the data extraction process. All remaining articles were reviewed for thematic extraction by one member of the research team (K.S.D.) using the established coding framework. Using the technique of constant comparison, the coding framework was iteratively revised through discussions about the emerging themes during regular team meetings.12 Once all articles were coded, we reviewed the entire coding framework, which represented all the expert and stakeholder opinions extracted from the articles, to finalize the categorization of primary themes and subthemes. We conducted further analysis of the extracted data to determine dominant themes by year of publication. We used NVivo 10 (QSR International, Doncaster, Australia) to analyze our data.
We identified 1,482 articles for review from our initial database search. Additional articles were added from hand searching references (16), the gray literature (5), and an updated database search (4). Of the identified articles, 214 met the inclusion criteria (see Figure 1). The majority of the articles were from authors in the United States (144; 67%), focused on the 80-hour workweek (164; 77%), and expressed opinions regarding the impact of the RDH restrictions on all surgical specialties (116; 54%). Most articles focused on education and training (195; 91%) and patient care (149; 70%). Most authors were attending surgeons (155; 72%) and from an academic institution (143; 67%) (see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A467 for additional article characteristics).
The emerging themes were organized into three overarching categories: (1) impact of the RDH restrictions, (2) surgery has its own unique culture, and (3) strategies going forward (see Figure 2). Within each category, we identified various subthemes and perspectives, which are described in the following paragraphs with examples from the included articles. We also organized the themes by year of publication revealing trends of dominant opinions in the published literature and ongoing themes since the implementation of the RDH restrictions. These trends highlight both the need to address the concerns of stakeholders that have been present for over a decade and the culmination of these opinions in the belief that RDH restrictions alone are insufficient to create change (see Figure 3).
Category 1: The impact of the RDH restrictions
Theme 1: Effects of the RDH restrictions on trainees.
Service versus training.
The concept of service versus training was used to express concerns over the effects of the RDH restrictions on the training and educational experience of surgeons, suggesting that learning opportunities should not be regulated by an arbitrary time limit and that time used for educational purposes should not be considered “work.” Authors were in support of reducing the service requirements for surgical residents, moving away from the Halstedian model, which “imbued the art of surgery with a deeply rooted sense of responsibility and powerful work ethic,”13 to an era that employs alternative human resources to reduce and regulate the “scut” work assigned to residents.
There should be no limitation, however, on the hours devoted to learning, whether in conferences, the library, on rounds, in the operating rooms, at home, and at the bedside of a sick patient. Why limit these hours?14
Authors saw the shift to team-based care and the promotion of humanistic values as positive outcomes of the RDH restrictions. However, they were concerned by the decline in professionalism that resulted from the shift away from patient-focused care toward shift work, suggesting that the RDH restrictions implemented by regulatory bodies were overriding the patient’s need for the surgeon who was present during the operation and that training residents to watch the time did not prepare them for real-world practice. This mixed effect on professional identity was thought to lead to ethical dilemmas for trainees. For instance, they may want to remain in the hospital to continue a patient care experience but be forced to leave and miss the educational opportunity, or they may remain and have to falsify their hours worked.
The current regulations have placed adherence to an artificial timeline ahead of any patient obligation. It is a struggle to teach commitment to residents when shifts, not patients, dictate residents’ priorities.15
Quality of life.
The impact of the RDH restrictions on residents’ quality of life is a complex issue. There were many anecdotal stories and survey results suggesting that surgical residents’ quality of life improved. However, this improvement seemed to be primarily in the early years of residency and potentially at the expense of education and patient care. Some authors felt that residents faced additional stressors associated with the increased intensity of training within the shortened workweek, since workloads remained unchanged or were transferred from junior to senior residents. The impact of shift work on trainees’ health was also a concern, as was the need for a lengthened training program to produce competent surgeons.
Residents who have trained since duty hour limits were implemented are more satisfied with their work–life balance and less susceptible to burnout and depression. We do not know, however, whether these gains have come at the expense of other “competing goods” (quality of education, continuity of care).16
Preparedness for practice.
The reduction in residents’ presence in the hospital and a perceived disruption in the mentor–mentee relationship had authors concerned about residents’ level of preparedness for independent practice. They suggested that less independence in the operating room and a discontinuity of patient care created a training environment that was not representative of real practice. The authors appeared to believe that this situation prevented surgical trainees from entering practice with confidence, resulting in many seeking additional training.
A major question that I constantly wrestle with is: at the end of my time-limited training will I be competent to operate independently?17
Theme 2: Effects of the RDH restrictions on patient care.
Quality of care.
The complexity of the health care process and the unforeseen repercussions of these changes had many stakeholders questioning the quality of care provided under these regulations. Those who felt patient care had improved associated the change with processes other than well-rested residents—for example, the increased involvement of staff surgeons in patient care or successful transitions to team-based care. However, few offered such positive opinions about the impact of the RDH restrictions on patient care. Those who did—proponents of these restrictions—were theorizing about the impact and speaking anecdotally, not citing evidence. In contrast, a plethora of publications suggested that no change had occurred or that the restrictions had a negative impact on patient care.
There is insufficient evidence linking length of resident hours to patient safety generally. There is ample evidence that such restrictions have no or negative effects on surgical patient safety.18
Improved patient safety via reduced resident fatigue.
Some authors argued that those who choose a career in surgery are more tolerant of sleep deprivation and therefore should be gauged on a different scale than those who choose other medical specialties and industries. Thus, the same restrictions should not be applied to all specialties evenly. Skeptics of the RDH restrictions pointed out the lack of evidence of a direct causal relationship between provider fatigue and patient safety and noted that studies from other industries were often referenced to support the argument that fatigue impacted patient care. However, they acknowledged that fatigue eventually limits an individual’s ability to function at full capacity; thus, prevention and mitigation strategies are needed, including strategic napping or fatigue-related training that creates opportunities for staff to recognize the symptoms of fatigue or that allows residents to rest more while in the hospital.
Fatigue resulting in medical errors is blamed for poor outcomes, and restricting duty hours has been touted as the solution. Not so fast! I am not convinced of the causal relationship. Yet.19
Continuity of care.
The increase in patient handovers, the absence of resident–surgeons treating patients postoperatively, and the decreased exposure to clinical material as a result of the RDH restrictions were concerns expressed by authors who suggested that these restrictions were a detriment to patient care. Any positive impact, they argued, was undone by the dangers of additional postoperative handovers. Counterarguments to this criticism were that training and tools to improve communication among health care team members offset the dangers of these extra transfers and that handovers should always be a prominent factor in resident training since they have an important impact on patient safety.
Concerns with resident/fellow fatigue must be balanced with the potential miscommunications that occur during handoffs, which can have patient safety implications.20
Even those who think that the present limits will disrupt continuity of care have never claimed that residents should be on duty without stop for weeks on end, which means that continuity of care must be disrupted at some point to give those residents a break.21
Theme 3: Effects of the RDH restrictions on faculty.
Roles and responsibilities.
Published opinions stated that some of the responsibilities previously held by residents have been transferred to faculty, reducing their available time for research activities and mentoring trainees. Authors discussed how the structure of the health care system has changed and how the complexity of medical care has increased. Their concern was that the effects of the RDH restrictions added further challenges for faculty who were already struggling to adapt to the new health care paradigm. However, many also felt that these restrictions were an opportunity to improve service delivery and the training environment.
The pressure due to the lack of sufficient number of residents is transferred to the remaining medical personnel, making educational activities and clinical research suffer.22
Authors considered inadequate supervision to be a contributor to medical errors, especially with less experienced trainees. However, they also perceived a decline in trainees’ exposure to supervising faculty due to residents’ reduced presence in the hospital and the increased workloads of faculty. Alternatively, some authors were concerned that the RDH restrictions increased supervision, resulting in reduced educational opportunities and delayed readiness for independent practice. A deterioration of the mentor–mentee relationship also was thought to be a consequence of these restrictions.
The main untoward effects of work hour restrictions for surgical residents have been a decrease in outpatient experience, diminished exposure to faculty who are now busy taking up the slack, and considerable loss of the educational value of continuity in patient care.23
Too much supervision—especially for senior residents—may prevent a resident from developing the necessary judgement, skills and responsibility to function as an independent practitioner.24
Quality of life.
Authors thought the transfer of responsibilities to faculty and the reduction in residents’ skill development and experience resulted in an increased burden on faculty. The RDH restrictions appeared to have no perceived positive impact on faculty members’ quality of life. The negative repercussions of these restrictions could only be addressed with strategies to improve the quality of residents’ training and to redistribute workloads among other health care professionals.
Some teaching hospitals have shifted some patient care to nonresident services or have hired more residents, but most have relied heavily on simply redistributing workload among existing residents, and wresting some additional patient care out of a mostly reluctant faculty.25
Theme 4: Effects of the RDH restrictions on the health care system.
Authors discussed the financial burdens associated with adaptation strategies mitigating the challenges that accompanied the RDH restrictions, such as hiring ancillary staff to manage work previously assigned to residents as well as adapting simulation facilities and acquiring new technological resources to create more efficient training environments. Some were concerned that not all hospitals could financially support these changes and that, without funding, some residency programs may close.
In the current climate of decreasing hospital reimbursement, hospitals that provide care to large indigent patient populations may find it particularly difficult to finance these changes.26
Authors considered the lack of financial support and human resources to be barriers to effectively adapting to the RDH restrictions. Many stakeholders proposed strategies to amend the surgical training program system design and service delivery to improve on the traditional ways of training residents and managing care. Some strategies were proposed as necessary solutions but were not preferred outcomes, including a lengthened training period and increased number of residents. Changes to the system design that would promote self-regulation and team-based care were viewed as an improvement, not just a mitigation strategy.
Is it not time to move beyond the issue of how many hours people work, who is in control, and get to the hard work of redesigning residency training for the realities of a health care system that is likely to be vastly different from the one we have today? If you are not hearing the hoof beats of change then you are not listening. The current system is unsustainable.27
Category 2: Surgery has its own unique culture
Among the opinions published on the RDH restrictions in surgery, there was a desire to communicate to the public and policy makers that surgery is different from other medical specialties and that medicine is different from other industries. Skills acquisition, the need for honed peri- and intraoperative judgment, technical skills development, and the emergency nature of surgical care were some of the reasons justifying the need to recognize the unique nature of surgical training and practice within the RDH paradigm. Current regulations, with a “one size fits all” approach, were viewed as insufficient for surgical culture, training, and practice. Even those who accepted that the regulations were necessary still expressed concern that the regulations alone, without strategic adaptations, could result in inadequately trained surgeons (see Table 1 for illustrative quotations relating to this category).
Category 3: Strategies going forward
Experts and stakeholders recommended potential adaptation strategies that policy makers and researchers could use to overcome challenges within the RDH paradigm (see Table 2 for illustrative quotations relating to this category).
Changes to training modalities.
Authors articulated how the RDH restrictions cannot be implemented successfully without other changes to the surgical training program system design. However, there was a lack of consensus on how to redesign training to meet these goals. Some supported the use of simulations and technology to make training more efficient. Others suggested the reallocation of workload, flexible regulations (by specialty and/or year of residency training), and competency-based evaluations.
Need for evidence.
There was concern over the paucity of high-quality research available to provide a confident assessment of the effects of the RDH restrictions. Authors expressed a desire for data-driven policy changes, evidence supporting the implementation of these restrictions, and adequate metrics to evaluate the impact of these changes on surgical training.
No new RDH restrictions.
Many authors referred to the fact that little to no data exist to support the continued implementation of the RDH restrictions. Terms such as “arbitrary” and “radical” were used to describe these mandated regulations. The announcement of additional regulations restricting hours further resulted in an increased volume of opinion articles. Although one nonprofit advocacy group encouraged further restrictions,28 the majority expressed a desire to prevent further restrictions, as no high-quality data existed to support the success of the current restrictions.
Enforcement of/compliance with the RDH restrictions.
Opinions varied on the best approach for enforcing the RDH restrictions, ranging from local, hospital-level enforcement to monitoring by quality assurance, medical, or administrative organizations. Authors felt that residents and institutions had not been fully compliant with these regulations; thus, any observed effects were potentially misleading. Authors believed that the current enforcement models encouraged the masking of noncompliance; fears of losing accreditation and pessimism about providing adequate training and patient care encouraged an environment where residents underreported their hours worked.
Flexibility in regulations.
Opposition to the “one size fits all” model suggested that some specialties have more obstacles to meeting the RDH requirements—for example, in surgery. Program directors appealed for specialty-specific flexibility. However, some stakeholders cautioned against too much flexibility, fearing a backlash from the public, and stressed the need for remaining within the RDH goals. Additionally, some authors suggested flexibility by level of experience—that is, senior residents should have less regulated duty hours to ensure their development of competence during the final years of training.
The themes we identified represent opinions regarding the impact of the RDH restrictions on resident education, patient safety, faculty, and the health care system. Surgeons agreed on the uniqueness of the surgical culture, especially how it was impacted by these restrictions, and the need for strategies going forward. We aimed to describe various viewpoints regarding the effects of the RDH restrictions in surgery by synthesizing opinions in an ongoing debate and by determining the intensity behind some of the arguments. Despite some differences of opinion, repeatedly authors focused both on adapting the educational and patient care systems to fit the changes in RDH and on studying these changes in a scientific manner. Furthermore, one theme was consistent across all the years of data we studied—the need to change the surgical training program system design and to produce successful adaptation strategies to mitigate the impact of the RDH restrictions (see Figure 3).
Providing patient-focused care is considered a core attribute of a surgeon’s professional identity, as is a strong sense of obligation to the patient and to the surgical hierarchy.29 Erosion of this sense of identity and the creation of a “shift-work” mentality has many surgical educators fearing for the future of the discipline. The RDH restrictions may bring humanistic values30 back into residency training, but the opinions published since the implementation of these restrictions suggest that more needs to be done to preserve the patient-centered focus and the rigorous and immersive training process.2,31,32
Surgeons viewed their culture as unique, and they opposed the RDH “one size fits all” model. Part of this unique culture is surgeons’ ability to withstand longer work periods without rest. Authors thought they should not therefore be compared with others, not only those in different specialties but also those in different industries, where the atmosphere is unlike that in the operating room. We found a bounty of opinions from surgical experts and educators requesting changes to improve training and patient care, but very few supported further RDH restrictions. Authors instead seemed to be appealing for flexibility in such regulations.
Our findings may inform a policy agenda for decision makers in surgical residency education and the prioritization of research for scientists involved in education and health policy studies. Not coincidentally, the Flexibility In Duty Hour Requirements for Surgical Trainees (FIRST) Trial was recently released. The results suggest that less restrictive and flexible RDH policies in surgery are feasible without impacting patient outcomes or worsening resident wellness or the perceived quality of education.33 The FIRST Trial is also an example of current efforts to conduct high-quality studies evaluating the impact and optimal design of RDH restrictions. As attending surgeons, residents, and program directors are all focused on the potential educational ramifications of RDH changes, further high-quality studies are needed to evaluate the effects of these restrictions on the learning and professional development of surgical trainees.
Published opinions suggest that the increased workload for faculty has resulted in a decline in their quality of life, but this shift in workload could be a benefit to patient care and resident training. Faculty time must be used effectively and their personal health and well-being protected, but a change in surgical practice to more hands-on involvement by faculty in patient care may counteract the negative effects of the RDH restrictions on patient care and provide further learning opportunities for residents.26,34,35
Finally, the RDH restrictions may present an opportunity to implement mitigation strategies for fatigue management, not only to produce physicians who are less tired but also to create a culture of high-functioning surgical teams where fatigue is identified and addressed without persecution.1,36 Indeed, the currently proposed ACGME changes to the Common Program Requirements focus both on changes to RDH restrictions (e.g., flexibility in scheduling for patient care and education) and on supporting resident wellness, identifying fatigue and burnout, as well as considering faculty well-being.37
Within surgical specialties, patient care and decision making are rarely performed in isolation. Nonverbal cues can reveal when a team member is fatigued; the other team members then can compensate for any decrease in function resulting from that fatigue or suggest that the team member rests. The emerging themes we identified suggest that a transition to effective team-based care in combination with fatigue mitigation strategies, like incorporating fellow surgeons and other health care staff, can reduce the burden associated with the RDH restrictions and improve health care delivery.1,23,31,38–41 These and other findings from our thematic analysis may guide future policy and regulatory changes (see Table 2).
Strength and limitations
Our results provide both insight into the implications of the RDH restrictions and context to support previous publications on this topic.3,5–10 Our systematic approach ensured a comprehensive amalgamation of viewpoints from experts and stakeholders in this field. The diversity and experience of the research team allowed us to be confident in our categorization and interpretation of the themes. This review is particularly timely as the ACGME is considering major changes to RDH requirements in response to many of the voices cited here and new scientific evidence.37
Limitations of our study were that the opinions included were restricted to the published literature and therefore did not represent individuals with unpublished opinions. Additionally, some countries, which may have different experiences and opinions, were disproportionately represented in our data; thus, some themes may not be widely applicable across health care systems worldwide.
Published opinions from the surgical community suggest that RDH restrictions alone are insufficient to achieve the desired outcomes of improved patient safety, resident well-being, and educational outcomes. These authors also argued that surgical training has a unique culture within medicine. In light of these perceptions, adaptation strategies should be supported with funding and resources, and the implications of the RDH restrictions should be closely monitored for quality assurance using appropriate metrics. Furthermore, authors identified areas that should be targeted to protect the integrity of the surgical discipline, including the change in professionalism to a “shift-work” mentality, increased disruptions in the continuity of care, poorer training outcomes, and a lack of preparedness for practice. From the perceptions of the various stakeholders in surgical education cited here, we identified areas for new policies. Although many expressed negative opinions toward the RDH restrictions, other voices supported changing the old system of training. Careful consideration of the intent and consequences of RDH restrictions could aid programs in training residents within this paradigm and improve not only patient care but also the health care system itself.
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4. Drolet BC, Sangisetty S, Tracy TF, Cioffi WGSurgical residents’ perceptions of 2011 Accreditation Council for Graduate Medical Education duty hour regulations. JAMA Surg. 2013;148:427–433.
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