Are these the changes we want? Commentary on surgical training.

There has been a steady flow of commentary about the declining interest among medical students in general surgery residency training. As a result of the Bell Commission and as part of an attempt to abate this decline, there are ongoing changes in our surgical training. I fear these changes will create poor, unprepared surgeons. I have experienced this era, over the last decade, from the time I entered medical school until the time I recently completed my residency. I am troubled by the consequences of these changes. While in medical school, there were absolutely no time restrictions on work hours. During a 1-month rotation, the second-year surgical resident was off only Sunday afternoons. This amounted to 152 hours a week for 4 weeks! The general surgery program had its required educational conferences on Saturday. Sundays were reserved for formal attending rounds. Work hours were never less than 110 hours a week. Yet these residents benefited from outstanding training. Residents were focused on proper and effective patient care, excellent surgical technique, and continually updating their medical knowledge. After this, I went across the country to New York for residency. For the first 3 years, I worked 100 to 125 hours a week. We were on call every third night. However, during my third year, we were reviewed by the Committee for Interns and Residents (CIR) and the Bell Commission. Our hospital was cited and fined, and work hours were drastically reduced. Call became every fourth night, and the post-call residents left at 0700 (7 AM). The most alarming change I have seen over the past 2 years is not an improvement in patient care but a drastic decline in patient care! There are several reasons to explain the decline. The focus of the Bell Commission and the New York State Code 405 was that a sleep-deprived resident was responsible for the death of a patient in a New York City hospital. Therefore, several time regulations were instated. Of these, the most prominent were limitations of work to no more than 24 consecutive hours and not more than 80 hours per week. As with any change, there are unexpected costs. The consequences of these new time regulations defy the basis of our training and have led to a frightening decline in patient care. First, continuity of care, one of the most emphasized principles of surgical training, is impossible. After 24 hours of call, residents are required to leave the hospital. They are absolutely not allowed to participate in morning rounds, because this would violate their requirement of having 24 hours off after a 24-hour working call. Residents cannot see the patients on whom they operated the previous day, and they cannot reassess the patients they admitted over night. Any clinical activity after 24 hours would violate the regulations and result in a significant fine for the hospital. With this system, it is impossible for residents to experience the daily progress of their patients. Further, not only is resident training compromised, but also this system is detrimental to patient care. The basis of serial clinical assessment depends on repeat examinations by the same examiner. Another problem arises in the care of the postoperative patient. No one knows more about a patient than the resident who performed the operation. Was it a routine colectomy or were there many adhesions requiring copious dissection, possibly slowing return to bowel function? Only the operating resident would know these answers. Although information can be verbally passed on, or “signed out,” terms such as “difficult,” “low,” “large,” and so on are subjective and have different meanings to different residents. As a result, decisions are altered and patient care may be compromised. Second, residency becomes “shift-work.” Regardless of what happens, after a 24-hour call, residents are required to leave the hospital. Residents are not able to participate in an operation on a patient for whom they cared for all night. Their learning is attenuated by the law that states they must leave the hospital after 24 hours. They will never see the significant pathology found at operation. The outcome is only realized the following day, again, during “sign outs.” In not a more significant situation is the adage “a picture is worth a thousand words” more applicable. The conversation the following morning may be, “oh yeah, by the way, it was a necrotic colon cancer.” Obviously, this one-sentence conversation cannot replace the expeCorrespondence: Inquiries to Ian K. Komenaka, MD, General Surgery, New York Methodist Hospital, 506 6th Street, Brooklyn, NY 11215; fax: (718) 780-3154; e-mail: en03@hotmail.com