Training Trends: British surgeon offers cautionary tale about limit on trainee duty hours

Lack of Evidence

In introducing Lord Ribeiro, Gerald Healy, MD, past president of the American College of Surgeons and professor of otology and laryngology at Harvard Medical School, said the new U.S. rules have not been thought through. “We talk about outcomes?” he said. “Nobody has thought about the outcomes for the patient in all of this discussion about reduced hours of training.”

Lord Ribeiro said the new rules were put into place in the U.K. without evidence showing that such a system will improve patient safety. “Where is the evidence?” he said. “We need hard evidence that we are improving patient safety, that we are actually improving patients’ outcomes as a result of reducing the duty hours.” In the U.S., the ACGME has acknowledged that studies have produced no evidence, either positive or negative, that reducing duty hours has an effect on patient safety.

Training Issues

The number of training hours per week in the U.S. will not be cut to U.K. levels, but Dr. Ribeiro said it’s the lack of flexibility that causes problems with education.

“It’s all the bits inside it and the rigidity that’s the problem,” he said. The continuity in training and in patient care have been hit hard in the U.K. as a result of the new limits, he added.

“Trainees are often attached to two or three different consultants,” Dr. Ribeiro told his U.S. listeners. “The idea that you have your team, your group around you who you nurture, you support and you promote and you advise, that is going rapidly. And that has come out of one single regulation. And this is something you need to guard against.”

He said that before the new rules took effect, trainees could be expected to receive 21,000 hours of training. Now, he said, “our calculation was that they would be lucky to get 8,000 hours”—below the 10,000 hours of experience generally regarded as the requirement to become an expert in a field.

“It doesn’t matter whether you’re a concert pianist or whether you’re a tennis player or whether you’re a surgeon, you need on average 10,000 hours of experience to change you from being a competent performer into an expert,” he said. “Ten thousand hours. When I trained, and I’m sure just about everyone in this room, when you trained, it was quite common to clock up 30,000 [to] 35,000 hours during your training period. This is the reality of what’s happening. Surgery is different. It isn’t just about reading the books and getting a feel for what your specialty is about. It’s actually applying it and being able to put it into practice by operating. And not just by operating, but going back to reassess patients before making the decision to operate.”