Cutting Through The Crap

Tuesday, August 13, 2013

Consequences


Duty hour restrictions on first-year general surgery residents have been linked to a 25.8% reduction in operating case load, according to a study published online July 10 in JAMA Surgery. 
The findings represent the first published data on the effects of the 16-hour cap implemented by the Accreditation Council for Graduate Medical Education in July 2011, the authors report. 
"If the 16-hour shift were to be extended to all postgraduate year levels, one can anticipate that additional years of training will be needed to maintain the same operative volume," write Samuel I. Schwartz, MD, from the Harbor-University of California at Los Angeles Medical Center, Torrance, and colleagues.
An old guy like me can't write about this without sounding like an old guy like me. But from the moment these restrictions were put in place, I predicted such consequences. Yeah, yeah, I trained in the days of the iron men (and, not all that frequently back then, women.) If it was borderline crazy to be in the hospital as much as I was -- on some rotations 12 out of 14 nights (the easier ones were 36+ hours of 48); and, as chief resident of the trauma service, for two months straight -- I always thought it was the only way I was going to learn everything I needed to learn, to see everything I needed to see before foisting myself upon a trusting public.

Friends in the world of academic surgery have told me of their concerns for years: that trainees behave as if it's shift work; that they're not getting the kind of experience we got when we were in residency. And it's been evident in those finishing their training: for one thing, they're not willing (not universally true, of course) to work as hard in practice as people of my generation did. Maybe that's not entirely bad: I burned out younger than I'd have thought. But they're also opting for post-residency fellowships in surgical sub-specialties: cancer, biliary, breast, etc. It has impacts both good and bad: the good is, probably, better training in those particular areas; the bad is the lack of surgeons capable of doing a broad range of things, which particularly affects smaller towns.

I've spoken a couple of times to friends I have in the American College of Surgeons, suggesting what's needed is a mentoring program for people just out of training, given the lower level of experience. It'd be a perfect thing for recently retired surgeons to do. But, far as I know, there's not any major movement afoot. I recognize the logistics would be difficult, especially in smaller locations.

The good news: I guess I don't have to care anymore. Until I need an operation. On the other hand, even if a fabulous surgeon were available, I'm half of a mind to let nature take its course and let Medicare spend its money on someone more deserving.

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