Learning to be a surgeon is similar to learning to play an instrument: talent is moulded by focused teaching, many hours of thoughtful practice, performance review, observation of peers and refinement of skills. It is crucial that reduced working hours for surgical Trainees do not negatively impact on this process.
Three years ago, when I was a fifth-year Trainee, I was involved in a robust discussion with colleagues about the impact of safe working hours on FRANZCOG training. I argued that the term was misleading – while reduced working hours may lead to less fatigue, it would also lead to less training time and potentially to specialists who were less skilled and therefore less safe than those who had worked longer training hours. It was a corridor discussion, and I thought little more of it, until one of those colleagues contacted me recently to ask me to write an article on the topic. Ironically, when she called I was working in a position formerly held by two full-time doctors. I was regularly at work 80–100 hours per week, continually first on-call for my unit, and this situation had been sustained for 12 months. I could barely remember the conversation, let alone identify with my previous conviction that reduced working hours were a negative imposition on medical trainees.
Across Europe and the USA, as well as in Australia, there has been a strong push over the last two decades to reduce the number of hours worked by doctors. This has been with the aim of improving patient safety, but also the health and well-being of doctors. These reductions have been legislated in parts of North America (Code 405, ACGME National Guidelines)1,2,3 and the UK/Europe (New Deal4, European Working Time Directive5). Although there is no such legislation in Australia, the Australian Medical Association (AMA) has been a powerful advocate for reduced working hours for doctors through their Safe Hours Audits of 2001, 2006 and 2011, and the voluntary Code of Practice – Hours of Work, Shiftwork and Rostering for Hospital Doctors.6
There is a significant body of evidence on the effects of fatigue on motor skills and judgment.7,8,9 Clearly, prevention of levels of fatigue that impair doctors’ skills and put patients at risk is crucial. This involves management of the roster patterns, as well as the number of hours worked. It is a complex issue, however, as the circadian rhythm disruption of shiftwork can potentially cause more fatigue than traditional on-call rostering.10 It is recognised that there is variation on how roster patterns and accumulated sleep debt affect different individuals and to what degree this causes impairment in those practitioners with differing levels of experience. Concerns have also been expressed that the improvement in patient safety that may be gained by shorter shifts is partly negated by the decreased continuity in patient care.11
More recent literature on reduced working hours for doctors investigates the implications for medical training and, in particular, surgical training. The European Working Time Directive (EWTD) introduced an average 58-hour working week in 2004, moving to 56 hours in 2007 and 48 hours in 2009. The Association of Surgeons in Training (UK) strongly expressed concern about the training effects of the EWTD in a number of publications, including a position statement12 and an editorial in the International Journal of Surgery.13 These documents refer to a number of studies that demonstrate a specific reduction in surgical training opportunities since the introduction of the EWTD. The Section of Surgery of the European Union of Medical Specialists published a position statement stating that the EWTD is: ‘in direct and severe conflict with former EU legislation to train competent surgical specialists.’14 One of the papers sometimes quoted to justify the position that reduced working hours do not adversely affect postgraduate medical training is a systematic review of 72 studies on reduced hours and outcomes, published in 2011 in the BMJ.15 The only conclusion from this analysis is that reducing working hours to less than 80 per week has not adversely affected outcomes for patients or postgraduate training in the USA. It is an interesting report to read in its entirety, though no conclusions could be drawn about the impact of reducing working hours to less than 56 or 48 hours per week, owing to conflicting results across institutions and specialties.
Studies and comments that compare doctors’ working hours with those of professional groups such as aircraft pilots can underestimate the importance of other aspects of training. It is true that both pilots and doctors are in a position of responsibility for others and at times will need to make life-and-death decisions in an instant. Both groups are also susceptible to fatigue, which may impair performance. However, this is not the whole picture. Becoming a gynaecological surgeon involves dexterous development under the guidance of a master teacher. In this way it is more similar to learning to play a musical instrument at a high level: a technical foundation is secured initially, followed by many hours of regular practice, ongoing supervision from an interested expert and continual refinement of skills. As with musicians rehearsing a new piece of music, mindless repetition of entire procedures doesn’t improve skill efficiently. A procedure can be broken down into specific elements, which are then practised until they are mastered. In many cases, this practice may be achieved in a simulated setting. Critical evaluation of performance is also crucial for both musicians and surgeons. Recording of Trainees’ procedures, both laparoscopic and open, is a useful and efficient training technique to achieve this.
The reduction of doctors’ working hours addresses risk associated with fatigue, but if introduced without specific attention to the subtlety of what makes a surgeon, then risk associated with lack of training may be increased. Prof Sir John Temple undertook a review of the impact of the EWTD on the quality of training.16 He makes the point that traditional models of training and service delivery in the setting of reduced hours dilute the quality and quantity of training, and waste learning opportunities. ‘Make every moment count’ is a phrase coined in relation to optimising the learning opportunity in every clinical situation encountered. A multidisciplinary approach is recommended to reduce unnecessary and non-training demands on junior doctors, by developing the roles of specialist nurses and surgical care assistants. Recognising and rewarding trainers is another recommendation of the review.
The Qualitative Research Report for the UK’s General Medical Council by Morrow et al17 further explores the impact of reduced working hours on medical training and adds support for implementing the recommendations of the Temple Review. ‘Education and training should be placed at the heart of service delivery,’ the report emphasises. While most respondents saw the long working hours of the past as counterproductive, simply reducing hours without a significant change to the educational component of their work added new stressors to training doctors.
It is difficult to take advantage of learning opportunities when exhausted and a return to the >80-hour working week is neither likely nor desirable. An Australian and New Zealand survey of surgical Trainees concluded that 55–60 hours per week was appropriate for balancing surgical training and fatigue risk.18 Work hours should not be considered in isolation, however. A package of changes needs to be introduced within a reduced working hours framework – attention to roster patterns, a multidisciplinary approach to non-training duties, prioritisation and integration of training into the working day, and maximisation of innovative educational techniques and opportunities. Trainers and Trainees should be actively involved in these changes, rather than passively accepting rosters which potentially impede good training and the development of clinical excellence.
- New York State Department of Health. Report of the New York StateDepartment of Health Ad Hoc Advisory Committee on EmergencyServices: supervision and residents’ working conditions. New YorkState Department of Health, 1987
- Accreditation Council for Graduate Medical Education. Report of theACGME work group on resident duty hours. Chicago, 2002.
- Iglehart JK. Revisiting duty-hour limits – IOM recommendations forpatient safety and resident education. N Engl J Med 2008; 359:2633-5.
- NHS Management Executive. Junior Doctors – The New Deal. London,July 1991.
- Directive 2003/88/EC of the European Parliament and of the Council of 4 November 2003 concerning certain aspects of the organization of working time. Official Journal L 299, 18/11/2003. P0009-0019.
- AMA’s National Code of Practice – Hours of Work, Shiftwork andRostering for Hospital Doctors, Jan 2005.
- Dawson D, Reid K. Fatigue, alcohol and performance impairment.Nature 1997; 388: 235.
- Taffinder NJ, McManus IC, Gul Y, et al. Effect of sleep deprivationon surgeons’ dexterity on laparoscopy simulator. Lancet 1998; 352:1191.
- Philibert I. Sleep loss and performance in residents and nonphysicians:a meta-analytic examination. Sleep 2005; 28: 1392-1402.
- Levy B, Dowson C, and Clark J. Are doctors working the EWTD nightshiftpattern less tired? Ann R Coll Surg Engl 2007; 89(suppl): 98-100.
- Horwitz LI, Moin T, Krumholz HM, et al. Consequences of inadequatesign-out for patient care. Arch Intern Med 2008; 168: 1755-60.
- Cresswell B, Marron C, Hawkins W, et al. Optimising working hours toprovide quality in training and patient safety: A position statement bythe Association of Surgeons in Training, Royal College of Surgeons ofEngland. 2009.
- Fitzgerald JEF, Caesar BC. The European Working Time Directive: Apractical review for surgical trainees. Int J Surg 2012; 10: 399-403.
- Benes V. The European working time directive and the effects ontraining of surgical specialists: a position paper of the surgicaldisciplines of the countries of the EU. Acta Neurochir (Wien) 2006;148: 1227-1233.
- Moonesinghe SR, Lowery J, Shahi N, et al. Impact of reductionin working hours for doctors in training on postgraduate medicaleducation and patients’ outcomes: systematic review. BMJ 2011; 342:d1580.
- Temple J. Time for Training: A review of the impact of the EuropeanWorking Time Directive on the quality of training. National HealthService: Medical Education England. May 2010. London, UK.
- Morrow G, Burford B, Carter M, Illing J. The impact of the WorkingTime Regulations on medical education and training: Final report onprimary research. A report for the GMC, 2012.
- O’Grady G, Harper S, Loveday B, et al. Appropriate working hours forsurgical training according to Australasian trainees. ANZ J Surg 2012;82: 225-229.