SC30.04 Impact of Working Time Directives on Thoracic Surgical Training: The North-American Experience

Abstract

The following is in part the STS, TSDA and AATS combined response to ACGME (collated and written up by Dr. Ara Vaporciyan) regarding the effect of Duty hour regulations on resident education in Thoracic Surgery in North America. This has impacted the profession in terms of additional cost from their much higher salaries, which are anywhere from 50% to 100% higher, but also a subtle but steady transfer of bedside teaching previously focused on the trainee to bedside teaching focused on the mid-level provider. Our profession still fills the bulk of its training position from general surgery graduates. Duty hour restrictions have contracted the ability of those programs to provide elective rotations in thoracic and cardiac. Limited exposure translates into limited interest and diminished applications. This is where we have felt the greatest impact. We, like all surgical professions, have developed an increasing variety of procedures necessitating expansion of our case log requirements. This puts pressure on trainees to participate in every available case. Appropriate cases are harder to find due to increasing case complexity and outcome reporting. Therefore, the inability to scrub on just one or two of these cases can be significant. While some large surgery programs have implemented float pools to ensure that all cases provide someone a learning experience most CT training programs are small and cannot implement that solution Even more difficult to overcome is when a trainee misses a rare postoperative event. As a high acuity specialty our patients will frequently develop rapid changes in their condition which, if not recognized, can quickly become catastrophic. Most occur in the immediate postoperative period at night. The use of mid-level providers and other services to cover call in an effort to preserve a trainee’s ability to do cases the next day prevents them from taking part in the bedside assessment and management of these rare events. One solution is to lengthen training to allow more opportunities but there is concurrent pressure to reduce what is already one of the longest training paradigms (up to 9 years for congenital surgeons without considering any time for research). Alternatively simulation has been used but these are expensive and are not easily implemented at all programs. While there is no clear study demonstrating documented impact on patient safety there are many surveys of resident and faculty perceptions of patient safety. The majority of these, especially in surgery, have shown that the perception is that safety is compromised. The increased number of handoffs, especially of high acuity cases, is frequently the target of that perception. The subtle aspects of the intraoperative findings cannot always be accurately communicated in a handoff. While patient safety data is not conclusive there is data on worse outcomes in spinal and meningioma surgery post implementation of duty hour regulations. These data may serve to corroborate the perceived concerns. Education, duty hour regulation, working time directives