CommentaryFrom OT Europe

Work-hour restriction and its influence on surgical education

Per Kjaersgaard-Andersen, MD
Per Kjaersgaard-Andersen

In the last 2 decades, an ongoing worldwide discussion of work-hour restrictions has had unintended consequences for residents, surgical education and training. Over time, medical staff also has been impacted by national decisions on maximum working hours per week, in average, for some period. I belong to the older generation of surgeons who were educated in the late 1980s and early 1990s, when we had limitations for maximum working hours, but not to the extent seen in some places in Europe now.

However, is it only the given time (in hours) and the reduction of those hours that limits or reduces a surgeon’s education, and thus, his or her opportunity to gain experience? I will be a bit provocative in two aspects of this topic: the hospital administrator’s view of the situation and the fact it is not only the hours, but what you do when you are on the job, that matters.

Administrator viewpoint

It is, of course, in the interest of hospital administrators to have employees working as many hours per week as possible, as this reduces the numbers of residents needed to cover a given position. It is also a more cost-effective solution if the unions indeed accept such employment bounds.

My thought is the hospital administrators, in general, do not work that way. They are also interested in having young medical residents who are relaxed and fresh take care of patients. In today’s society, hospitals and departments are judged on patients’ satisfaction with their treatment, as well as on the number of complications. In some countries, hospitals will soon be reimbursed according to levels of patient satisfaction and rates of complications, making it even more important to be focused on employees’ “readiness” to work.

Beyond work hours

My point is that it must be each department’s highest priority to determine how to organize its surgical training program and what tools can help “compensate” for the shorter time residents spend in the hospital now compared to a few years ago. Many educational materials have been written that contain good ideas for how to do this, and no two departments are doing the same to maximize resident education.

Early training in basic principles on phantoms, computer-guided surgical decision-making, limited hours per week in duties, bringing more hours per week in the operation theaters, one resident-one surgeon training relationships and several other approaches have been introduced. On top of this, open and critical feedback given from trained orthopaedic residents to trainees is always of a big help, as one naturally wants to do the best for the upcoming generation of orthopaedic surgeons.

In my department, when we consider surgery for patients and inform them about how the hospital process works and the departments will function during their procedures, we always tell them they may be operated on by one of our residents, but under the supervision of a seasoned surgeon. Next, we tell the patient this is important training to prepare the younger surgeons to assume major roles in patient care when the elderly surgeons leave for their pension. After such an explanation, I have never heard a patient decline having their surgery done by a resident.

Clearly, reduced hours at work also reduce the time spent in surgery. Keep in mind, however, if you are an orthopaedic resident, that it is not only the actual hours at work that determine your level of surgical training, but also how, and how well, the training is organized in the hours that you actually are working.

Disclosure: Kjaersgaard-Andersen reports no relevant financial disclosures.

Per Kjaersgaard-Andersen, MD
Per Kjaersgaard-Andersen

In the last 2 decades, an ongoing worldwide discussion of work-hour restrictions has had unintended consequences for residents, surgical education and training. Over time, medical staff also has been impacted by national decisions on maximum working hours per week, in average, for some period. I belong to the older generation of surgeons who were educated in the late 1980s and early 1990s, when we had limitations for maximum working hours, but not to the extent seen in some places in Europe now.

However, is it only the given time (in hours) and the reduction of those hours that limits or reduces a surgeon’s education, and thus, his or her opportunity to gain experience? I will be a bit provocative in two aspects of this topic: the hospital administrator’s view of the situation and the fact it is not only the hours, but what you do when you are on the job, that matters.

Administrator viewpoint

It is, of course, in the interest of hospital administrators to have employees working as many hours per week as possible, as this reduces the numbers of residents needed to cover a given position. It is also a more cost-effective solution if the unions indeed accept such employment bounds.

My thought is the hospital administrators, in general, do not work that way. They are also interested in having young medical residents who are relaxed and fresh take care of patients. In today’s society, hospitals and departments are judged on patients’ satisfaction with their treatment, as well as on the number of complications. In some countries, hospitals will soon be reimbursed according to levels of patient satisfaction and rates of complications, making it even more important to be focused on employees’ “readiness” to work.

Beyond work hours

My point is that it must be each department’s highest priority to determine how to organize its surgical training program and what tools can help “compensate” for the shorter time residents spend in the hospital now compared to a few years ago. Many educational materials have been written that contain good ideas for how to do this, and no two departments are doing the same to maximize resident education.

Early training in basic principles on phantoms, computer-guided surgical decision-making, limited hours per week in duties, bringing more hours per week in the operation theaters, one resident-one surgeon training relationships and several other approaches have been introduced. On top of this, open and critical feedback given from trained orthopaedic residents to trainees is always of a big help, as one naturally wants to do the best for the upcoming generation of orthopaedic surgeons.

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In my department, when we consider surgery for patients and inform them about how the hospital process works and the departments will function during their procedures, we always tell them they may be operated on by one of our residents, but under the supervision of a seasoned surgeon. Next, we tell the patient this is important training to prepare the younger surgeons to assume major roles in patient care when the elderly surgeons leave for their pension. After such an explanation, I have never heard a patient decline having their surgery done by a resident.

Clearly, reduced hours at work also reduce the time spent in surgery. Keep in mind, however, if you are an orthopaedic resident, that it is not only the actual hours at work that determine your level of surgical training, but also how, and how well, the training is organized in the hours that you actually are working.

Disclosure: Kjaersgaard-Andersen reports no relevant financial disclosures.