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Andrew L. Warshaw

Walking a tightrope on MGH’s training hours

By Andrew L. Warshaw
November 21, 2009

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THE PATH from medical school graduate to skilled, independent surgeon is long and rigorous. Those who travel it have much to learn along the way, not only about techniques to mend the ill and injured body, but also about the strength of human spirit, the dogged pursuit of elusive answers, and the bond formed when one life is entrusted to another. It is a challenge to balance these lessons with the need for sufficient rest.

The Massachusetts General Hospital surgical residency program has a proud tradition of training outstanding clinicians and leaders. Aspiring surgeons drawn to MGH represent an extraordinary group - gifted, highly motivated, ambitious, and committed to delivering the best care. They seek opportunities to immerse themselves in the many facets of the surgical journey, from the simplest stitch to the most complex resection, from spirited debates about tricky diagnoses to painful conversations with families. During their years of training, residents build a solid foundation of clinical wisdom and technical skills they will call upon for years to come.

Teaching hospitals are charged with shepherding this surgical metamorphosis during these crucial residency years. This remarkable process takes experience, practice, and perseverance - and precious time.

Since 2003, teaching hospitals have been required to limit work hours to 80 a week. The thinking behind this limit is logical. Too much work can mean a tired resident. Fatigue and lack of sleep can impair judgment, potentially leading to errors. Limiting work hours, therefore, could facilitate the rest needed for optimal performance and foster the balance between professional and personal life, easing the once-grueling residency schedules of the past.

Limiting work hours, however, also comes with significant drawbacks. Mandated limits lead to more handoffs between caregivers, increasing opportunities for miscommunication and creating a new set of errors that may offset any safety gained from well-rested residents. Shorter shifts also mean reduced time observing, practicing, and learning in the operating room, and less time with patients and families.

To meet the work-hours requirements, MGH has made substantial changes. No longer do our general surgical residents rotate through neurosurgery, urology, orthopedics, anesthesia, and otolaryngology. We have consolidated our daily teaching rounds into a mandatory five-hour weekly session. We have increased the number of residents and fellows, hired more physician assistants and nurse practitioners to handle work once performed by residents, added to faculty physician responsibilities, and shifted night duty assignments among residents. These changes have come at a price, both in educational opportunities lost and in financial investment, which has added to the overall cost of care. It is possible surgical residencies may need to be extended beyond the current five to seven years of training.

While we have assiduously implemented measures to bring our program into compliance with the 80-hour limit, a site visit in November 2008 by the Accreditation Council for Graduate Medical Education found several examples of residents who stayed beyond the limits to care for patients. In April, we received a letter warning us that accreditation of our surgical training program was at risk. We responded with data demonstrating that we had brought work hours into full compliance - a status we continue to sustain. Unfortunately, however, we just learned we have been placed on probation.

We are confident that upon review we will again be fully accredited, but still, this probation status is a difficult pill to swallow. Our training emphasizes responsibility to the patient and seeks to instill in residents a deep and uncompromising commitment to optimal care. When that beeper goes off, when a patient needs attention, residents must feel a personal responsibility to do whatever it takes to meet the needs of that patient - even if the weekly clock is striking 80. Such accountability is emblematic of the commitment doctors must make throughout their professional lives. It is a covenant that patients want and need and deserve.

Residency programs everywhere are desperately trying to balance the sound intent of duty-hour limits with the risks of unintended consequences, whether more errors associated with increased handoffs, a less-skilled doctor, or erosion of the doctor-patient bond amid a kaleidoscope of caregivers. Teaching the delivery of high-quality, compassionate patient care is a complex and dynamic undertaking. We must find the elusive “sweet spot’’ that lies at the nexus of adequate rest, sufficient intensity and duration of training, and continuity of care. To be successful in this search, we must look at resident duty hours within their complicated context rather than as an isolated issue.

Andrew L. Warshaw, M.D., is surgeon in chief at Massachusetts General Hospital and professor of surgery at Harvard Medical School.

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