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Less practice for surgeons-in-training after restrictions

By Andrew M. Seaman

NEW YORK (Reuters Health) - Surgeons-in-training had fewer opportunities to take part in operations after restrictions on their working hours were put in place in July 2011, according to a new analysis.

Researchers tracking a group of first-year surgical residents during 2011 and 2012 found the trainee surgeons took part in an average of 26 percent fewer operations than their counterparts in the previous four years.

"This is one of the dilemmas that educators have. These residents are simply not finding enough time to practice," said Dr. Samer Mattar, a professor at the Indiana University School of Medicine in Indianapolis who studies surgical training.

"You can't go to a pilot and tell them they can't use a flight simulator because it's time to go home," Mattar, who was not involved with the new study, added.

Under pressure from the public and government officials to reduce preventable medical errors by sleep-deprived doctors, in July 2011 the Accreditation Council for Graduate Medical Education (ACGME) restricted the shifts of the most junior trainee surgeons - first-year residents, who are also known as interns - to 16 hours and capped the shifts of the more senior residents at 28 hours.

The restrictions were built on existing regulations, enacted in 2003, that limited resident work weeks to 80 hours.

While many studies have examined the impact of the 2003 restrictions on residents, less is known about the effects of the latest changes.

A recent survey of more than 1,000 surgical residents found that about two of every three disliked the restrictions and most said the quality of their education had gotten worse (see Reuters Health article of May 17, 2013 here: http://reut.rs/12hvzo1).

For the new study, published in JAMA Surgery, researchers reviewed the case logs of 52 interns who were the first to work under the new restrictions, then compared those to the case logs of 197 interns from the four previous years.

Overall, the 2011 interns reported taking part in an average of 66 operations each. That compared to an average of about 89 operations per intern from 2007 through 2010.

Cases when the interns assisted more experienced surgeons and so-called major cases, when interns lead the procedure, both dropped. Residents are required to complete 750 major cases by the end of their fifth year.

"Our argument is that it's not just the major cases. It's the assisting cases and will lead you to enter your second year less prepared," said Dr. Christian de Virgilio, the study's senior author from Harbor-University of California at Los Angeles Medical Center.

In a paper recently presented at the American Surgical Association's annual meeting in Indianapolis, Mattar and his colleagues reported that about one in every five fellowship program directors, who oversee surgeons coming out of residency programs, already felt that new surgeons were unprepared to operate.

The new restrictions just complicate the problem, according to Mattar.

But Dr. Brian Drolet, a fifth-year surgical resident at Rhode Island Hospital in Providence, said it may not be disastrous for interns to lose 20 cases in their first year.

"The intern year isn't a heavy operating time… So I don't think that kind of change is going to have any meaningful impact on graduating numbers," said Drolet, who led the recent resident survey that found most thought their education was suffering, but was not involved in the new study.

Mattar told Reuters Health there are some possible solutions to getting surgeons more training, including tailoring a medical student's last year of school toward their chosen field and so-called early tracking.

"If residents can pick early on what their path is going to be… then they don't necessarily need to spend time learning other stuff they won't need in their careers," Mattar said.

De Virgilio said he believes the 16-hour restrictions should be repealed but the 80-hour week rule should stay in place.

"The duty hour rule has to have some flexibility and a sliding scale that certain specialties in medicine require much more training than others," he said.

SOURCE: http://bit.ly/K8qAyH JAMA Surgery, online July 10, 2013.

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