I hear and I forget. I see and I remember. I do and I understand.
—Confucius (551-479 b.c.)
The presidents of the Australian, British, Canadian, New Zealand, and South African Orthopaedic Associations join those of the American Orthopaedic Association and the American Academy of Orthopaedic Surgeons to form the Carousel Presidents organization. More than simply sharing English as their principal language of medical communication, the respective associations share common challenges and learn relevant solutions that are applicable to orthopaedic practice and education around the globe. One such endeavor that shares commonality across the continents is trainee education and the evolving regulatory pressures that orthopaedic educators face in the regulation of trainee duty hours in the new millennium. As Confucius suggested, to do is to understand … and to learn. In the tradition of William Halsted, we in the surgical disciplines particularly respect this tenet of education as it relates to the mastery of technical skills. However, it is this same need to acquire technical proficiency that produces additional consternation over the notion of work-hour limits in a world of time-defined surgical education.
Three underlying principles that are germane to resident duty-hour guidelines, as well as the reaction to such efforts, are universally applicable to all orthopaedic communities despite variation in the actual rules in each country. The central issue driving reform around the world is the need to improve patient safety and reduce medical errors related to fatigue of the treating physician. Two additional issues that have arisen in reaction to the duty-hour dilemma are the realization of the need for a transition to competency-based surgical education from the present time-defined training periods and a heightened awareness of the erosion of medical professionalism that is seemingly implicit in an environment that legislates a clock-punching mentality. Indeed, one might reasonably suggest that the central issue of work-hour guidelines is a mere surrogate for the discussion of these three important fundamental tenets of medical education.
To the point of optimizing patient safety and minimizing medical errors, it is interesting that only the Royal Australasian College of Surgeons (RACS)1, representing both Australia and New Zealand, and the Royal College of Surgeons of England2 have taken a formal stance on duty-hour limits for Fellows of the College as well as trainees. The RACS notes that "surgeons should be aware of the cumulative hazard of sleep and rest deprivation and take measures to avoid"1 such conditions, which they define as continuous work periods of greater than fourteen hours, less than a ten-hour continuous break in each twenty-four-hour period, and less than twenty-four hours per week when the surgeon is not working. Despite the well-intended effort in having such guidelines be applicable to active practitioners, John Batten, immediate past President of the Australian Orthopaedic Association, noted that "the introduction of safe hours in Australia for the medical profession still remains very much an aspirational aim"3 largely because of the manpower crisis that has resulted from years of restriction in medical school enrollment by previous administrations. Despite recent governmental efforts to create new medical schools and increase admissions to existing schools, the anticipated substantial increase in graduates will not be felt until 2012, and Batten goes on to comment that "although Doctors in Training are taking a strong stand (in favor of the RACS policy statement), the manpower situation results in more senior staff working somewhat longer hours to maintain continuity of patient care."3 One can logically assume that the ideals of prioritizing patient safety must also include accountability for the work hours of the most senior physicians caring for patients; however, attempts to implement strict work-hour limits for trainees have resulted in the unintended consequence of a demonstrable increase in work hours for the supervising surgeon. Denis Atkinson, immediate past President of the New Zealand Orthopaedic Association, noted that the aspirational guidelines of the RACS for trainee work hours are supported in New Zealand, but the apprenticeship model of training remains dominant and registrar work hours are still more patterned after those of their paired consultant than controlled by any regulatory body or governmental agency4. The 2008 Institute of Medicine report on "Resident Duty Hours: Enhancing Sleep, Supervision, and Safety" confirmed this impression by noting a seventy-two-hour weekly limit in New Zealand5. Restriction of work hours as a lever by which to improve quality of care continues to defy measurement and, consequently, validation.
Emerging from the discussion of trainee work-hour limitations, and the resulting reduction in the number of clinical encounters as learning opportunities, is the realization of the need for transition to a competency-based program of surgical education from the present time-defined training period. Integral to the British response to the European Working Time Directive has been a focus on the need for a competency-based educational system. The European Working Time Directive became law in 2004 and reduced the working hours for junior doctors to a maximum of fifty-eight hours per week, followed by a planned reduction to fifty-six hours in 2007, and the final decrement to forty-eight hours per week in August 2009, with a strict stipulation requiring eleven hours of continuous rest in every twenty-four-hour period regardless of the total weekly duty hours2. The Association of Surgeons in Training projected that the initial step reduction accounted for a 20% decrease in exposure to operative cases, and the second decrease to forty-eight hours added another 25% decrement, for an overall reduction of nearly 40% in elective case volume from prior to the European Working Time Directive6. Similarly, the British Orthopaedic Trainees Association (BOTA) ironically called the full implementation of these guidelines a "threat to the safety of patients" by providing for a cadre of future consultant orthopaedic surgeons with a "level of expertise … that will undoubtedly be significantly inferior to that currently taken as the minimum standard."7 They have called on the government to pass urgent legislation that would allow a profession-wide opt-out of the restrictions such that the average weekly contracted hours may be increased to sixty-five. Moreover, the BOTA has noted that, by forcing doctors into shift work, the European Working Time Directive restrictions have caused home and family life to suffer as well, despite an overall reduction in the proportion of the week spent at work. Recently, the Department of Health offered a voluntary plan that provided for all doctors, including both consultants and registrars, a one-time opt-out of the forty-eight-hour rule back to the fifty-six-hour limit when they signed on to their new posts in August 2009. The Royal College of Surgeons has also called for a "surgical opt-out" of the European legislation to achieve a sixty-five-hour work week as suggested by the BOTA8. Concurrent with the European Working Time Directive, the Modernising Medical Careers program was instituted in the United Kingdom in 2007 and sought to standardize graduate medical education by mandating more competency-based training rather than time-directed periods of service9. Despite some early bumps along the way, the Modernising Medical Careers program has eliminated a preliminary senior house officer position that previously could have lasted several years longer than the originally intended two-year term and has opened the door to actually streamline training times in some disciplines. Clare Marx, immediate past President of the British Orthopaedic Association, is a proponent of both work-hour limits and an explicit competency-based curriculum with fixed milestones for surgical training and advancement rather than a statutory period simply defined by years in service10. She further advocates that work schedules should be rearranged to prioritize education and suggests that shift work and night duty should be minimized for trainees under the new guidelines, or eliminated altogether, unless a credible educational experience can be provided around the clock. Provision of after-hours coverage in the setting of reduced house officer work hours has surfaced as a critical issue.
In contrast to the substantial work-hour limitations promulgated in many countries, Canada remains more flexible in its approach. Cyril Frank, President of the Canadian Orthopaedic Association, has noted that every province has slightly different rules, but most of Canada is still well above the world average for weekly work-hour limits; indeed, he suggests that it is still possible to work eighty hours in most areas11. The Professional Association of Internes and Residents of Ontario has defined a maximum of sixty work hours per week on shift rotations, such as the intensive care unit and emergency medicine, with a minimum of twelve hours off in between shifts12. However, orthopaedics has requested an exemption from the duty-hour limits with the most recent cycle of contract discussions as the sentiment is that the residents are not getting enough clinical exposure. South Africa is even more lenient, according to reports from John Shipley, President of the South African Orthopaedic Association13. The Health Professions Council of South Africa has limited trainees to fifty-six hours per week and no more than thirty hours continuously. However, registrars can elect to work paid overtime for up to eighty hours weekly, and there are no such regulations for specialists under state employment or in the private sector. Nevertheless, he notes that "time restrictions have not significantly affected post-graduate training,"13 and a typical registrar work week averages sixty-five hours in his center.
The final issue, the erosion of medical professionalism, is perhaps the most vexing and pervasive across all countries around the globe. While early reports in the United States have suggested lapses in quality of care, an increase in communication deficiencies during handoffs, a compromise of the learning experience, and an exorbitant cost of backfilling for restricted resident duty hours, our international colleagues have issued a more direct call to preserve surgical duty hours in the name of professional obligation. The statement of the Royal Australasian College of Surgeons noted that "the preservation of surgery as a profession and avoiding the development of a shift worker mentality is vital."1 Thomas Nasca, in his role as chief executive officer of the Accreditation Council for Graduate Medical Education in the United States, suggested that placing absolute time limits on a resident caring for patients precludes the nurture of altruism as a fundamental quality that we desire of physicians as professionals14. Indeed, there is substantial sentiment that trainees protest the artificial work-hour ceiling in deference to a desire to provide care for their patients as well as to optimize their educational experience as trainees15. Nonetheless, in the United States, we have legislated as a punishable offense, for both trainee and program director, the act of a trainee staying beyond the proscribed hours to continue on in the care of a critically ill patient that might also present a unique learning opportunity. Yet, the desired data to document improvement in the quality of patient care, enhanced medical education, or a reduction of medical errors as they relate to work-hour limits remain elusive nearly seven years following the 2003 introduction of reduced resident work hours in the United States16. Moreover, while most acknowledge the virtues of a competency-based program of resident education, educators struggle to develop precise competency expectations and the metrics by which to measure them for purposes of advancement decisions … especially in the surgical disciplines that involve the mastery of technical skills17. Nevertheless, by virtue of an intangible sense that defies quantification, many clinical medical educators recognize the impending perils of the erosion of medical professionalism at this same point into the work-hours experiment. Absent hard data regarding favorable changes in medical errors and patient safety, and without a competency-based educational program to test and implement, we find ourselves left only with the abstract and intuitive sense that mandated limits to work hours for medical trainees defy the ethos that engenders professionalism in the practice of medicine. After experiencing years of trainee work-hour limits of less than sixty hours, our most respected international colleagues are wrestling to return their duty-hour limits to the levels that are currently under attack in the United States. To legislate a further reduction in trainee duty hours outside the complicated context of educating a medical professional, and blind to the continued need to cultivate a sense of altruism and professionalism in tomorrow's physicians, is a mistake that the global orthopaedic community has identified and begun to articulate. We should all pause, listen, and learn together … from one another.