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June 2011CHICAGO — New limits on doctors in training in the United Kingdom (U.K.) have drastically reduced the amount of training they receive and may put patients in peril, a renowned retired British surgeon told listeners here on April 29 at the Annual Meeting of the Triological Society, held as part of the Combined Otolaryngology Spring Meetings.
Lord Bernard Ribeiro, FRCS, FACS, critiqued the British system, now in effect for two years, and offered it as a cautionary tale for the American medical system, where new rules for medical trainees, imposed by the Accreditation Council for Graduate Medical Education (ACGME), are scheduled to go into effect on July 1.
Lord Ribeiro presented as the Society’s Joseph H. Ogura, MD, lecturer.
Reduced Hours
Working hours allowed for doctors in training have been reduced in England from 58 in 2004 to 48 in 2009. In addition, the rules stipulate that 11 hours of continuous rest must be given in every 24-hour period immediately after the working period.
In the U.S., the cap on weekly hours will remain the same, 80 hours per week averaged over four weeks, but first-year post-graduates will be limited to 16 hours a day, effectively forcing a rest period. After the first year, a 24-hour workday is allowed, with “strategic napping” suggested. The hope is that the limits will reduce the number of medical errors committed by sleep-deprived residents.
The standards also emphasize the importance of supervision and teaching, as well as the patient handover process. Compliance is voluntary, but for those who choose not to follow the rules, accreditation may be in jeopardy.
In the U.K., “the rest requirement was crucial,” making training far too rigid to work well, said Lord Ribeiro, a former consultant surgeon at Basildon Hospital in England and former president of the Royal College of Surgeons of England. “And actually they’re not dissimilar from the rest requirements that you have in your ACGME rules.”
The new rules in the U.S. have drawn criticism, mostly for the 16 hour-a-day limit on first-year post-grads. Most of the comments on the rule have been negative, with some asserting that not enough time is left for quality education. The American College of Surgeons has been especially critical, expressing “very grave concerns” about the first-year limits, and predicting “a negative impact on patient safety and continuity of care unless there is a substantial increase in human resources to replace the residents.”
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.”
The restrictions have also limited the amount of time that trainees can spend doing emergency work, he said.
Impact
The effects of the limits on training in the U.K. will not be known until it is time for the new doctors to begin working independently, he said. “I fear that we may be creating a new generation of trainees; we won’t know until 2014 whether this has had an impact,” he said. “I suspect, and most of us suspect, and certainly the managers of hospitals in the U.K. are concerned, seriously concerned, that the product of doctors that we are producing and turning out at the moment will not be equivalent of what we’ve had before.”
Lord Ribeiro urged his U.S. counterparts to challenge leaders’ expectations about the new rules.
“It behooves us all, and you, to challenge government to provide the evidence,” he said, “get them to do an audit, make them provide the evidence that by reducing hours, you are improving the outcomes for patients.”
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