Rest requirements for residents unlikely to improve outcomes in 2 common surgeries

Jul 26, 2010

As the Accreditation Council for Graduate Medical Education seeks to improve patient care by further limiting the hours worked by medical residents, the Journal of Surgical Research will published a new study online on Monday reporting that outcomes in two common surgeries - appendectomy and laparoscopic cholecystectomy - were similar among residents who had worked less than 16 hours and those who had worked more than 16 hours.

The research team, led by investigators at Los Angeles Biomedical Research Institute (LA BioMed), concluded that requiring a five-hour rest period at night for surgical residents after 16 hours of work is "unlikely to improve the outcomes for these commonly performed operations."

The researchers reviewed 2,908 laparoscopic cholecystectomies, in which the is surgically removed through a small incision in the abdomen, and 1,726 appendectomies to remove patients' appendixes that were performed at Harbor-UCLA Medical Center from July 2003 to March 2009. These are the two most common operations performed by residents, and the two surgical procedures are often performed at night when residents are more likely to have worked a long shift.

The researchers compared outcomes in these two operations when they were performed during the day by surgical residents who had worked less than 16 hours and at night by surgical residents who had worked 16 or more hours. The researchers concluded that " and cholecystectomy operations performed at night by less rested and possibly sleep-deprived residents have similar good outcomes compared with those performed during the regular work day."

"In terms of the two most commonly performed operations by surgical trainees, the study suggests that limiting resident shifts to 16 hours of work is unlikely to improve ," said corresponding author Christian de Virgilio, MD, a LA BioMed principal investigator. "Training surgeons takes more time than many other medical disciplines because the residents must learn the craft of surgery along with patient care. By reducing the hours per day available for surgical training, residents would miss out on critical aspects of a patient's care. It will also further increase the costs and length of time to train surgeons. It currently takes 10-15 years after graduating from college to competently train surgeons."

The Accreditation Council for Graduate Medical Education is a private, non-profit council that evaluates and accredits more than 8,800 residency programs in 130 specialties and subspecialties in the United States, affecting more than 110,000 residents. Its 16-member task force charged with reassessing resident training program standards recently proposed a set of draft standards for medical resident education that would reduce duty periods of first-year residents to no more than 16 hours per day and would seek more supervision of first-year residents.

As the residents progress through their training, the task force set no specific limits on hours worked per day but encouraged residents to avoid fatigue by napping or resting during their shifts. The task force recommended the maximum weekly hours of resident training stay the same as the current standard of 80 per week averaged over four weeks.

The study published by the Journal of Surgical Research said the proposed changes in residents' duty hours "have the potential to profoundly affect surgical residency training nationally." It pointed out that limited work hours in Europe have resulted in decreased patient interaction, participation in 30% fewer operations per year, decreased ability to learn from more senior professionals, decreased ability to follow patients through their full clinical course and decreased participation in structured training.

"The accrediting agency should closely examine the data to determine if reducing surgical residents' work hours improves outcomes for surgical patients, and it should carefully consider the effect any reduction in duty hours has on the training of surgeons before adopting any further reductions," said Dr. de Virgilio. "The agency may wish to adopt a different standard for surgical residents, who need more hours on duty to ensure they have adequate time to learn the craft of surgery and follow a patient's care from pre-operation to post-operation."

The task force's standards are open for comment at this time, with final approval set for September and implementation scheduled for July 2011.

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