FIRST reflections: Impact of ACGME duty hours on CT practitioners
As a wife and mother of 3, I recognize that we, as a specialty, need to find ways to support our trainees and their families and to help them live happy lives conducive to functioning outside the hospital. I believe that we can do this with support, mentorship, and advocacy; I do not believe that it requires cutting back on the training that we are all, in the end, so incredibly grateful to receive.”
Dr. Mara Antonoff is an assistant professor of thoracic and cardiovascular surgery at UT MD Anderson Cancer Center. She performed her General Surgery training at the University of Minnesota, 2004-2012, and her Thoracic Surgery Training at Washington University, as a traditional 2-year resident, 2012-2014.
Dr. Stephens: “There is nothing that replaces being bedside. Whether it be a postoperative patient struggling with low cardiac output syndrome overnight, or a patient with a high pressor requirement the etiology of which you are trying to uncover, or a patient you have been following who suddenly arrests, the value of seeing a patient’s trajectory longitudinally is critical to developing clinical acumen. When as an attending I will get called in the middle of the night about a postoperative patient not “doing well,” I will be drawing on my years of being on call and being bedside with my patients.
Patient care is the ultimate goal, and it is clear that overworked residents are at higher risk for making mistakes that jeopardize patient care, which nobody wants. However, the restrictions that duty hours place don’t allow the flexibility necessary for a specialty such as ours, and in fact strict adherence to such regulations inhibits opportunities for our learning. Also concerning is the “shift-work” mentality that seems to be increasingly pervasive with the implementation of duty hours. As has been well documented, and as I have seen personally, the constant patient handoffs that are requisite to implementation of duty hours pose their own perils in terms of patient safety.
Ultimately, these are our patients and we are responsible. Once we are attendings, those responsibilities will not be turned off after we have reached some prespecified hour limit.
The question then remains how best to implement a system across a wide variety of programs that ensures both patient safety and adequate clinical experience in the context of a culture of patient responsibility for the residents. As the NEJM study (N Engl J Med. 2016 374:713-2) shows, flexibility in implementation of duty hours did not result in increased complications, but resulted in improved resident satisfaction in continuity of care and handoffs. In my opinion, this study then encourages specialties such as ours to be more flexible in work hours, to encourage residents when there is a learning opportunity that previously they would be prohibited from taking part in to take hold of that opportunity, and to use this flexibility in implementation of duty hours to combat the invading “shift-work” mentality that will only jeopardize patient care.”
Dr. Elizabeth H. Stephens, MD, PhD is a Cardiothoracic Surgery, resident, PGY4, at Columbia University, New York, as an Integrated I-6 Resident.
Dr. Brown: “I took the traditional 5-year of General Surgery + 2 years of Cardiothoracic Surgery training route to becoming a General Thoracic Surgeon. My General Surgery experience was invaluable to my development as a surgeon. However, after all of those years of General Surgery cases and minimal exposure to Cardiothoracic Surgery cases, coupled with minimal overlap between the two specialties with regard to patient care, I found the learning curve in fellowship to be very steep. I was fortunate to train in a program with phenomenal physician extender support [APPs] in addition to top-notch colleagues in other specialties and excellent nursing, which allowed me to spend the majority of those 2 years in the operating room and completely focused on patient care. During that final phase of training, I welcomed flexibility with regard to the work-hour restrictions to ensure that I was acquiring the experience I needed prior to starting my own practice.”
Lisa M. Brown, MD, MAS, Assistant Professor of Thoracic Surgery, UC Davis Health System, Calif.; Training Institution: Washington University
Dr. Lee: “I started my surgical training in 2005, 2 years after the implementation of the 80-hour workweek restriction. Fortunately for my personal life, my training program took the restriction very seriously and strictly enforced it. As a result, I had scheduled periods off from work, and rarely worked more than 80 hours per week over the course of general surgery. On those occasions that I did, the next weeks, or preceding weeks would be shorter, to compensate. As a product of a 4+3 Thoracic Surgery residency in this environment, the 80-hour workweek extended to my subspecialty training. Our cardiac surgery time strictly enforced the go-home post-call policy. As a result, I believe my duty hours during Thoracic Surgery are likely shorter overall than many other programs.
