Tuesday, December 27, 2005

80 hour week Redux

This month's American Journal of Surgery contains an interesting article from the Dept. of Surgery at Baylor in Houston entitled Impact of the 80-hour work week on resident emergency operative experience. As I have written previously, I am not convinced the 80 hour work restrictions will deal an even hand to surgeons in training, or their future patients.

The current study is a retrospective comparison of the emergent operative experiences of PGY-4 and PGY-5 residents before (group 1) and after (group 2) imposition of work hour restrictions. Similar to a previous study published in JACS (reviewed extensively by Dr. Bard Parker), overall operative numbers were essentially unchanged between the two groups. However, the residents' "numbers" were preserved by increasing performance of less complex, less emergent procedures that were previously performed by more junior residents:

The mean total of procedures per resident as primary surgeon was similar between the groups. However, a qualitative analysis of the level of technical complexity of laparotomies showed an obvious shift from advanced to basic procedures: a resident in group 2 (after work hour restrictions) performed, on average, 40% fewer advanced laparotomies compared with those in group 1. In addition, there was a concomitant 44% increase in the mean number of basic laparotomies done by residents in group 2.

(in the comments section) In other words, senior residents are now preserving their "numbers" by encroaching on the operative experience of their juniors. The long-term consequences of this phenomenon are obvious and must be addressed.
Additionally, there was a dramatic drop in the residents' experience acting as first assistant or as teaching assistant in major emergent operative procedures:
An 82% reduction in the opportunity to participate as a learning first assistant in a major abdominal trauma procedure means that a senior resident will often be called upon to do a major trauma case without ever having had the opportunity to see one. Similarly, fewer cases done as teaching assistant translate into less opportunity to develop operative independence and technical self-confidence. Surgical training is thus evolving into a "read one, do one" situation.
While some may not feel that decreased operative experience is necessarily a bad thing (I don't share that view), what was more striking was the change in continuity of care.
The total number of cases that required a return to the operating room for another procedure during the same hospital stay remained the same throughout the study period. However, in group 1, 60% of reoperations were performed by the same resident who did the original procedure. This percentage dropped to 26% in group 2.
I have always felt that continuity of care is one of the most important hallmarks of general surgery; basically, the surgeon shoulders the responsibility to see his or her patient through the perioperative period, and be the one responsible for returning the patient to the OR in the case of an adverse event if at all possible. In fact, the surgeon's ability to deal with postoperative complications is perhaps his/her most important asset. If residents are only taking their own patients back to the OR a quarter of the time, they are missing out on what I would consider a critical part of their education. From the article's abstract:
Conclusions: The ACGME regulatory environment is adversely affecting the emergency operative experience of surgical residents. Our findings underscore the need to develop alternative methods to augment the residents' operative experience.
For another perspective, Dr. Parker has had other interesting posts about this subject -- here, here, and here.
Experience is the worst teacher; it gives the test before presenting the lesson.
Experience teaches only the teachable.
—Vernon Law