That's the title of a very interesting article in the New York Times' Well blog. Here's a brief excerpt.
For the past decade, in response to increasing pressure from politicians, unions and sleep experts, the Accreditation Council for Graduate Medical Education, the organization responsible for accrediting American medical and surgical training programs, has been working to cap the hours that residents work.
. . .
For nearly a century, surgical residency had been a period of both intensive experience and increasing responsibility under the guidance of more experienced surgeons. More recent research has affirmed that approach, demonstrating the strong link between a surgeon’s operative skill, the number of operations performed and patient outcomes. With limits set on their time at the hospital, young surgeons-in-training had fewer opportunities to care for patients or scrub in on operations. While previous generations of trainees had the luxury of participating in at least one operation a day, new trainees had only enough time to be involved in two or maybe three operations each week.
Calculating the number of hours “lost” by cutting back on in-hospital time, surgical leaders estimated that young surgeons-to-be were now missing out on as much as a year’s worth of experience.
. . .
Surgical training programs scrambled to make up for less time and cover the ever-expanding body of knowledge by creating online educational tools and offering trainees experiences in simulated operating rooms and trauma resuscitations using electronic mannequins and foam rubber models.
But as The Annals of Surgery study reveals, even the best-equipped simulation labs cannot replace a year’s worth of lost experience.
There's more at the link. Very worthwhile reading, particularly in these days of disruptions to medical insurance and uncertainty about the future of health care. It's not very comforting to people like me, who are growing older, have had multiple surgeries in the past, and know we're likely to need repeat surgeries in the not too distant future.
Peter
The article is missing the entire point of reduced working hours for docs - reduction in errors made due to fatigue. Much as with airline pilots, duty day restrictions exist because the human body does not function well without adequate rest. While the points made are accurate and experience does indeed count, there is no assessment of the net difference between the increase in surgical mistakes due to inexperience versus the reduction in surgical and other (general practice) mistakes made due to fatigue which I have to believe is a non-trivial factor in the overall medical error numbers.
ReplyDeleteAcknowledging the point that peoples' abilities do degrade with fatigue (at a rate which varies wildly with the individual and even then varies with many factors), the only solution is to keep surgeons in residence longer. Not release them for private practice until they've had some number of operations. That's not going to go over very well, either.
ReplyDeleteSide note: a few years ago, my wife had to have emergency surgery. I can't tell you how relieved I was to see the young surgeon wearing an "AA" Army Airborne pin on his lapel. He had been doing surgery in the Army in the sandboxes, getting in lots of reps. LOTS of reps.
It's not just the surgeons, either. Every single residency training program out there is being similarly degraded in training hours, and for what?
ReplyDeleteYes, people who are tired do make mistakes. That is a given. However, there is no one who governs the hours that attendings work once they have graduated from training. We work tired because there is no other way to get the job done. And it's partly because I learned to know what my limits were during residency and fellowship that I understand how to cope with it now.
There is also a lack of actual evidence that shows that the reduced training hours are making medicine safer, despite how intuitive the conclusion may be. Reducing the duty hours increases the number of hand-offs and sign-outs, which increases the amount of errors made. It also decreases the ability of residents to follow any given patient through a disease process, an important learning tool.
It's not quite as cut-and-dried as cutting hours to cut mistakes.
The solution is simple. Partner with violent US cities and overseas locations that see a lot of action, so they can do "community service" there, and get practice on a dozen non-litigious clients a day. Win-win.
ReplyDeleteWhat about surgeons who voluntarily work double shifts on a regular basis, in two separate hospitals? I know their driving skills improve, but ...
ReplyDeleteSuper late to the party here, but PediEM has got it right.
ReplyDelete@Rolf: the most demanding and litigious patients I've dealt with (on average) are "disadvantaged" people from the inner city. Of course most are no more or less reasonable than anybody else, but the proportion of people from "rough neighborhoods" who threaten some sort of legal action (this includes shouting "I'm gonna sue you and this hospital!" loudly and often) as a means of getting what they want is way higher than in the general population.