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Reduced surgical training hours harm patients and education, Canada study finds

BMJ 2014; 348 doi: (Published 07 April 2014) Cite this as: BMJ 2014;348:g2627
  1. Michael McCarthy
  1. 1Seattle

Reducing surgical trainees’ work hours has led to worse patient outcomes and poorer trainee performance on certification programmes without clearly improving the trainees’ sense of wellbeing, a new study claims.1

The systematic review was conducted as part of a project by the Royal College of Physicians and Surgeons of Canada to develop a consensus policy document on duty hour reductions for doctors in training.2

Najma Ahmed, of the University of Toronto in Ontario, was the lead author of the paper, which was published online by the journal Annals of Surgery.

In 2003 the Accreditation Council for Graduate Medical Education in the United States mandated an 80 hour duty limit for residents as an average over four weeks, and in 2011 the council mandated that duty periods for first year trainees should be no longer than 16 hours.

The goals of the duty hour limits were to reduce trainees’ fatigue, in order to improve patient safety, resident wellbeing, and the quality of residents’ education.

However, many surgical education programme organisers have complained that limits are unsuitable for surgical training, severely reducing trainees’ clinical experience and increasing the risk of poor patient outcomes by reducing the continuity of care and increasing the number of handovers.

In their review Ahmed and her colleagues identified 135 articles that fitted the study’s inclusion criteria, 78 (58%) of which were graded as low to very low quality and 57 (42%) as moderate to high quality.

The researchers found that no overall improvement in patient outcomes seemed to result from implementing reduced duty hours, and some studies showed an increase in complication rates among high acuity patients—specifically in neurosurgery, cardiac surgery, and critical care.

They also found that no improvement in the quality of education seemed to be associated with the reduction of duty hours, and in some specialties performance in certification exams had declined.

For example, of the 33 (58%) articles graded as moderate to high quality that looked at resident education, 13 (48%) reported that education outcomes had worsened after reduced duty hours were implemented and 11 (41%) reported no change, using such measures as the American Board of Surgery’s certification data.

The implementation of the 80 hour workweek mandate was associated with improvements in residents’ wellness, but little improvement and some negative effects were reported to be associated with the 16 hour duty rules.

Survey studies found that residents thought the reduction in duty hours had worsened education and patient safety, the researchers said.

In their discussion the researchers noted the limitations of their review, particularly the heterogeneous nature of the studies, which may have looked at the effect of different mandates, over different time intervals, in different clinical situations, and which, for the most part, were not randomised.

The researchers concluded that, given the lack of evidence that the mandated work duty reductions had significantly benefited residents’ wellness and the evidence that they might potentially harm patients and the quality of surgical training, such mandates should be reconsidered—at least with regard to surgical trainees.

The researchers wrote, “An approach that centers on the training mandate of residencies and allows a degree of flexibility will be necessary if we wish to preserve robust educational and patient level outcomes without further prolonging an already arduous and lengthy training experience. It is well time to reconsider the direction of [reduction in duty hours] as it relates to surgical training, as the recent erosion of resident training time has not achieved the desired results.”


Cite this as: BMJ 2014;348:g2627


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