FIRST reflections: Impact of ACGME duty hours on CT practitioners

Several months ago, Dr. Bilimoria and his colleagues published the long awaited study in NEJM essentially contradicting adverse effects of strict duty hours on patient outcomes (N Engl J Med. 2016 374:713-2). The study, known as the FIRST trial, was published in the March issue of Thoracic Surgery News. Although the study enrolled general surgery residents, its conclusion impacts no specialty more than cardiothoracic surgery, where frequent handoffs complicate tedious perioperative care of sick patients stall learning opportunities for young trainees.

As Dr. Shari Meyerson eloquently noted in her perspective piece for Thoracic Surgery News (March 2016, page 4), surgery training needs to adapt to meet the modern day needs of trainees to rest and spend time with family and friends, with those of exposure to complex clinical scenarios in a short residency period. Arguably, CT surgery trainees are some of the most motivated and driven; to limit their experience on a national level may be shortsighted. On the other hand, appropriate incorporation of advanced practice providers (APPs) may help allay some patient care challenges, free valuable family time, and allow thoracic residents to function well in a more flexible ACGME duty-hour paradigm. To add thoracic relevance to the findings of Dr. Bilimoria and his colleagues, the debate is brought to Thoracic Surgery News by our colleagues from different training pathways below:

Dr. Antonoff: “Due to the timing of my medical school matriculation, I completed my surgical clerkships in the preregulated duty-hour era. I had expectations of what my life would be like as a surgeon when I applied for the general surgery match, and frankly, my expectations prepared me for a life that would revolve around my education, my technical training, and my commitment to patient care. During my years as a junior resident, my surgical training program gradually adapted in recognition of the new guidelines, but it took time. I spent 3 years in the research lab, and, after I came out as a senior resident, I discovered that the rules of the game had totally changed. While duty hours for me, as a senior trainee, were still fairly open, I found that my interns and junior residents had to play by completely new rules. In some ways, on rare occasions, I felt frustrated and resentful of the fact that my duties as a chief resident and thoracic fellow included many of the tasks that I’d done as an intern, because my interns would ‘expire’ after 16 hours. However, much more often, I felt bad for those who came after me.

They seemed desperate to operate, eager to see their patients’ problems through to resolution, and embarrassed to have to end their days earlier than the more senior members of the team. I feel fortunate that I had years of frequent in-house call after long days in the operating room and followed by post-call days of more operating. I finished my junior years without fear of any sick patient in the hospital, I finished my general surgery training without fear of any emergent operation, and I finished my fellowship with confidence that I could get a patient through just about anything if I had access to a cannula.

My early experiences as an attending have certainly kept me humble, and I’ve spent many a night worried about my patients, rethinking choices that I’ve made and stitches that I’ve thrown. But I thank my lucky stars that I was exposed to phenomenal training, and that I had the privilege and opportunity to work the hours needed to reach a reasonable level of safety! I can only imagine that if I’d have spent fewer nights in the hospital, that I’d feel even more anxiety and nausea at this early stage of my surgical career.

As elaborated in the editorial by Dr. Birkmeyer (N Engl J Med. 2016;374:783-4), it is not surprising that patient outcomes did not immediately depend on whether the programs had adhered strictly to the ACGME duty-hour rules. Limited numbers of patients experience critical events during shift change, and hospitals are evolving to function with greater reliance on midlevel practitioners and attending physicians. I would not expect the short-term results of duty-hour flexibility to demonstrate any impact on patient care. However, I do fear that there will be a mid-term impact on trainee accountability and autonomy, which will ultimately impact the competence of the attending surgeons of the future, and downstream potential long-term impact on day-to-day patient outcomes.

As a wife and mother of 3, I recognize that we, as a specialty, need to find ways to support our trainees and their families and to help them live happy lives conducive to functioning outside the hospital. I believe that we can do this with support, mentorship, and advocacy; I do not believe that it requires cutting back on the training that we are all, in the end, so incredibly grateful to receive.”

Dr. Mara Antonoff is an assistant professor of thoracic and cardiovascular surgery at UT MD Anderson Cancer Center. She performed her General Surgery training at the University of Minnesota, 2004-2012, and her Thoracic Surgery Training at Washington University, as a traditional 2-year resident, 2012-2014.

Dr. Stephens: “There is nothing that replaces being bedside. Whether it be a postoperative patient struggling with low cardiac output syndrome overnight, or a patient with a high pressor requirement the etiology of which you are trying to uncover, or a patient you have been following who suddenly arrests, the value of seeing a patient’s trajectory longitudinally is critical to developing clinical acumen. When as an attending I will get called in the middle of the night about a postoperative patient not “doing well,” I will be drawing on my years of being on call and being bedside with my patients.

Patient care is the ultimate goal, and it is clear that overworked residents are at higher risk for making mistakes that jeopardize patient care, which nobody wants. However, the restrictions that duty hours place don’t allow the flexibility necessary for a specialty such as ours, and in fact strict adherence to such regulations inhibits opportunities for our learning. Also concerning is the “shift-work” mentality that seems to be increasingly pervasive with the implementation of duty hours. As has been well documented, and as I have seen personally, the constant patient handoffs that are requisite to implementation of duty hours pose their own perils in terms of patient safety.

Ultimately, these are our patients and we are responsible. Once we are attendings, those responsibilities will not be turned off after we have reached some prespecified hour limit.

The question then remains how best to implement a system across a wide variety of programs that ensures both patient safety and adequate clinical experience in the context of a culture of patient responsibility for the residents. As the NEJM study (N Engl J Med. 2016 374:713-2) shows, flexibility in implementation of duty hours did not result in increased complications, but resulted in improved resident satisfaction in continuity of care and handoffs. In my opinion, this study then encourages specialties such as ours to be more flexible in work hours, to encourage residents when there is a learning opportunity that previously they would be prohibited from taking part in to take hold of that opportunity, and to use this flexibility in implementation of duty hours to combat the invading “shift-work” mentality that will only jeopardize patient care.”

Dr. Elizabeth H. Stephens, MD, PhD is a Cardiothoracic Surgery, resident, PGY4, at Columbia University, New York, as an Integrated I-6 Resident.

Dr. Brown: “I took the traditional 5-year of General Surgery + 2 years of Cardiothoracic Surgery training route to becoming a General Thoracic Surgeon. My General Surgery experience was invaluable to my development as a surgeon. However, after all of those years of General Surgery cases and minimal exposure to Cardiothoracic Surgery cases, coupled with minimal overlap between the two specialties with regard to patient care, I found the learning curve in fellowship to be very steep. I was fortunate to train in a program with phenomenal physician extender support [APPs] in addition to top-notch colleagues in other specialties and excellent nursing, which allowed me to spend the majority of those 2 years in the operating room and completely focused on patient care. During that final phase of training, I welcomed flexibility with regard to the work-hour restrictions to ensure that I was acquiring the experience I needed prior to starting my own practice.”

Lisa M. Brown, MD, MAS, Assistant Professor of Thoracic Surgery, UC Davis Health System, Calif.; Training Institution: Washington University

Dr. Lee: “I started my surgical training in 2005, 2 years after the implementation of the 80-hour workweek restriction. Fortunately for my personal life, my training program took the restriction very seriously and strictly enforced it. As a result, I had scheduled periods off from work, and rarely worked more than 80 hours per week over the course of general surgery. On those occasions that I did, the next weeks, or preceding weeks would be shorter, to compensate. As a product of a 4+3 Thoracic Surgery residency in this environment, the 80-hour workweek extended to my subspecialty training. Our cardiac surgery time strictly enforced the go-home post-call policy. As a result, I believe my duty hours during Thoracic Surgery are likely shorter overall than many other programs.

Everyone hears the rumors of other programs lying about their duty hours. Fortunately, mine was not one of these. Despite this, or because of this, I received top-notch training. At the same time and more importantly, I started a family. I married my wife a week before my internship started, and am still married to the same person. We had two precious daughters during my Thoracic Surgery years. I don’t believe this would have been possible without duty-hours restrictions.

To create an environment where such a task was possible, my program hired an army of mid-level practitioners to deal with the day-to-day tasks of providing cardiothoracic surgical care to the patients, both in the intensive care unit and on the ward.

I rarely had to write a history and physical during Thoracic Surgery training. I consented fewer patients than I have fingers on my hands. I pulled even fewer chest tubes. I can now no longer remember having pulled a central line. I learned these tasks when I was a junior resident. What I did instead as a senior resident was perform over 900 cardiothoracic procedures as the primary surgeon. Now, as an attending surgeon, I still don’t write full histories and physicals by myself. I certainly don’t pull chest tubes and central lines. I consent patients by having a conversation with them, which I did as a resident, but I don’t bring a piece of paper with me in to the clinic room. I have a physician assistant who helps me fill in the gaps.

©Hemera Technologies/Thinkstock

In 8 months of practice, I have performed over 15 thoracic organ transplants, repaired over 15 aortic dissections, half of whom required root replacements, performed more double-valve surgeries than straightforward single-valve replacements, started a minimally invasive atrial fibrillation surgical program, and applied almost every shred of knowledge and experience gained in 3 years of Thoracic Surgery Residency to a busy clinical practice. Most importantly, I continue to come home and watch my two daughters grow up.

With that perspective, I don’t believe the question should be whether or not programs should have the flexibility to enforce or not enforce duty-hours restrictions. It should be, how could every program find a way to effectively train residents to be good physicians and still allow them a personal life?”

Dr. Anson Lee is an Assistant Professor of Cardiac Surgery, Stanford University, Calif.; Training: 4+3 CT Residency, at Washington University, St. Louis.

Ms. Bohlman: “As a physician assistant in cardiac surgery, I represent the reality that physicians with a critical patient population appreciate consistency in their patient management. However, working in a university hospital setting also requires that surgical residents receive appropriate training. With the recently implemented duty restriction hours on resident training programs, advanced practice providers (APPs) have been utilized as an excellent solution for scheduling conflicts without compromising patient care. An example to this point is evident in my own place of work.

Approximately 1 year ago, our surgical intensive care unit transitioned from resident care to a combination of residents and APPs. At that time, the APPs were tasked with the complete care of all cardiac surgery patients. This change reduced the quantity and acuity of patients for which the residents were responsible and therefore allowed for more flexible hours along with a more manageable patient load. These changes, among others, have contributed to improved patient outcomes in the cardiac surgery patient population within our institution. With the increase in APPs that have training in various specialties, there comes an increasing ability to not only fill the gaps in scheduling but to do so with an extension of the providing physician. Although the NEJM article demonstrated no difference in patient outcomes between resident programs with restricted duty hours versus more flexible duty-hour policies, I foresee the future of medicine focusing on trained APPs as a complement to the care that the residents provide.”

Allison Bohlman is a Physician Assistant at Rush University Medical Center in the Integrated cardiovascular thoracic intensive care unit.

Several months ago, Dr. Bilimoria and his colleagues published the long awaited study in NEJM essentially contradicting adverse effects of strict duty hours on patient outcomes (N Engl J Med. 2016 374:713-2). The study, known as the FIRST trial, was published in the March issue of Thoracic Surgery News. Although the study enrolled general surgery residents, its conclusion impacts no specialty more than cardiothoracic surgery, where frequent handoffs complicate tedious perioperative care of sick patients stall learning opportunities for young trainees.

As Dr. Shari Meyerson eloquently noted in her perspective piece for Thoracic Surgery News (March 2016, page 4), surgery training needs to adapt to meet the modern day needs of trainees to rest and spend time with family and friends, with those of exposure to complex clinical scenarios in a short residency period. Arguably, CT surgery trainees are some of the most motivated and driven; to limit their experience on a national level may be shortsighted. On the other hand, appropriate incorporation of advanced practice providers (APPs) may help allay some patient care challenges, free valuable family time, and allow thoracic residents to function well in a more flexible ACGME duty-hour paradigm. To add thoracic relevance to the findings of Dr. Bilimoria and his colleagues, the debate is brought to Thoracic Surgery News by our colleagues from different training pathways below:

Dr. Antonoff: “Due to the timing of my medical school matriculation, I completed my surgical clerkships in the preregulated duty-hour era. I had expectations of what my life would be like as a surgeon when I applied for the general surgery match, and frankly, my expectations prepared me for a life that would revolve around my education, my technical training, and my commitment to patient care. During my years as a junior resident, my surgical training program gradually adapted in recognition of the new guidelines, but it took time. I spent 3 years in the research lab, and, after I came out as a senior resident, I discovered that the rules of the game had totally changed. While duty hours for me, as a senior trainee, were still fairly open, I found that my interns and junior residents had to play by completely new rules. In some ways, on rare occasions, I felt frustrated and resentful of the fact that my duties as a chief resident and thoracic fellow included many of the tasks that I’d done as an intern, because my interns would ‘expire’ after 16 hours. However, much more often, I felt bad for those who came after me.

They seemed desperate to operate, eager to see their patients’ problems through to resolution, and embarrassed to have to end their days earlier than the more senior members of the team. I feel fortunate that I had years of frequent in-house call after long days in the operating room and followed by post-call days of more operating. I finished my junior years without fear of any sick patient in the hospital, I finished my general surgery training without fear of any emergent operation, and I finished my fellowship with confidence that I could get a patient through just about anything if I had access to a cannula.

My early experiences as an attending have certainly kept me humble, and I’ve spent many a night worried about my patients, rethinking choices that I’ve made and stitches that I’ve thrown. But I thank my lucky stars that I was exposed to phenomenal training, and that I had the privilege and opportunity to work the hours needed to reach a reasonable level of safety! I can only imagine that if I’d have spent fewer nights in the hospital, that I’d feel even more anxiety and nausea at this early stage of my surgical career.

As elaborated in the editorial by Dr. Birkmeyer (N Engl J Med. 2016;374:783-4), it is not surprising that patient outcomes did not immediately depend on whether the programs had adhered strictly to the ACGME duty-hour rules. Limited numbers of patients experience critical events during shift change, and hospitals are evolving to function with greater reliance on midlevel practitioners and attending physicians. I would not expect the short-term results of duty-hour flexibility to demonstrate any impact on patient care. However, I do fear that there will be a mid-term impact on trainee accountability and autonomy, which will ultimately impact the competence of the attending surgeons of the future, and downstream potential long-term impact on day-to-day patient outcomes.

As a wife and mother of 3, I recognize that we, as a specialty, need to find ways to support our trainees and their families and to help them live happy lives conducive to functioning outside the hospital. I believe that we can do this with support, mentorship, and advocacy; I do not believe that it requires cutting back on the training that we are all, in the end, so incredibly grateful to receive.”

Dr. Mara Antonoff is an assistant professor of thoracic and cardiovascular surgery at UT MD Anderson Cancer Center. She performed her General Surgery training at the University of Minnesota, 2004-2012, and her Thoracic Surgery Training at Washington University, as a traditional 2-year resident, 2012-2014.

Dr. Stephens: “There is nothing that replaces being bedside. Whether it be a postoperative patient struggling with low cardiac output syndrome overnight, or a patient with a high pressor requirement the etiology of which you are trying to uncover, or a patient you have been following who suddenly arrests, the value of seeing a patient’s trajectory longitudinally is critical to developing clinical acumen. When as an attending I will get called in the middle of the night about a postoperative patient not “doing well,” I will be drawing on my years of being on call and being bedside with my patients.

Patient care is the ultimate goal, and it is clear that overworked residents are at higher risk for making mistakes that jeopardize patient care, which nobody wants. However, the restrictions that duty hours place don’t allow the flexibility necessary for a specialty such as ours, and in fact strict adherence to such regulations inhibits opportunities for our learning. Also concerning is the “shift-work” mentality that seems to be increasingly pervasive with the implementation of duty hours. As has been well documented, and as I have seen personally, the constant patient handoffs that are requisite to implementation of duty hours pose their own perils in terms of patient safety.

Ultimately, these are our patients and we are responsible. Once we are attendings, those responsibilities will not be turned off after we have reached some prespecified hour limit.

The question then remains how best to implement a system across a wide variety of programs that ensures both patient safety and adequate clinical experience in the context of a culture of patient responsibility for the residents. As the NEJM study (N Engl J Med. 2016 374:713-2) shows, flexibility in implementation of duty hours did not result in increased complications, but resulted in improved resident satisfaction in continuity of care and handoffs. In my opinion, this study then encourages specialties such as ours to be more flexible in work hours, to encourage residents when there is a learning opportunity that previously they would be prohibited from taking part in to take hold of that opportunity, and to use this flexibility in implementation of duty hours to combat the invading “shift-work” mentality that will only jeopardize patient care.”

Dr. Elizabeth H. Stephens, MD, PhD is a Cardiothoracic Surgery, resident, PGY4, at Columbia University, New York, as an Integrated I-6 Resident.

Dr. Brown: “I took the traditional 5-year of General Surgery + 2 years of Cardiothoracic Surgery training route to becoming a General Thoracic Surgeon. My General Surgery experience was invaluable to my development as a surgeon. However, after all of those years of General Surgery cases and minimal exposure to Cardiothoracic Surgery cases, coupled with minimal overlap between the two specialties with regard to patient care, I found the learning curve in fellowship to be very steep. I was fortunate to train in a program with phenomenal physician extender support [APPs] in addition to top-notch colleagues in other specialties and excellent nursing, which allowed me to spend the majority of those 2 years in the operating room and completely focused on patient care. During that final phase of training, I welcomed flexibility with regard to the work-hour restrictions to ensure that I was acquiring the experience I needed prior to starting my own practice.”

Lisa M. Brown, MD, MAS, Assistant Professor of Thoracic Surgery, UC Davis Health System, Calif.; Training Institution: Washington University

Dr. Lee: “I started my surgical training in 2005, 2 years after the implementation of the 80-hour workweek restriction. Fortunately for my personal life, my training program took the restriction very seriously and strictly enforced it. As a result, I had scheduled periods off from work, and rarely worked more than 80 hours per week over the course of general surgery. On those occasions that I did, the next weeks, or preceding weeks would be shorter, to compensate. As a product of a 4+3 Thoracic Surgery residency in this environment, the 80-hour workweek extended to my subspecialty training. Our cardiac surgery time strictly enforced the go-home post-call policy. As a result, I believe my duty hours during Thoracic Surgery are likely shorter overall than many other programs.

Everyone hears the rumors of other programs lying about their duty hours. Fortunately, mine was not one of these. Despite this, or because of this, I received top-notch training. At the same time and more importantly, I started a family. I married my wife a week before my internship started, and am still married to the same person. We had two precious daughters during my Thoracic Surgery years. I don’t believe this would have been possible without duty-hours restrictions.

To create an environment where such a task was possible, my program hired an army of mid-level practitioners to deal with the day-to-day tasks of providing cardiothoracic surgical care to the patients, both in the intensive care unit and on the ward.

I rarely had to write a history and physical during Thoracic Surgery training. I consented fewer patients than I have fingers on my hands. I pulled even fewer chest tubes. I can now no longer remember having pulled a central line. I learned these tasks when I was a junior resident. What I did instead as a senior resident was perform over 900 cardiothoracic procedures as the primary surgeon. Now, as an attending surgeon, I still don’t write full histories and physicals by myself. I certainly don’t pull chest tubes and central lines. I consent patients by having a conversation with them, which I did as a resident, but I don’t bring a piece of paper with me in to the clinic room. I have a physician assistant who helps me fill in the gaps.

©Hemera Technologies/Thinkstock

In 8 months of practice, I have performed over 15 thoracic organ transplants, repaired over 15 aortic dissections, half of whom required root replacements, performed more double-valve surgeries than straightforward single-valve replacements, started a minimally invasive atrial fibrillation surgical program, and applied almost every shred of knowledge and experience gained in 3 years of Thoracic Surgery Residency to a busy clinical practice. Most importantly, I continue to come home and watch my two daughters grow up.

With that perspective, I don’t believe the question should be whether or not programs should have the flexibility to enforce or not enforce duty-hours restrictions. It should be, how could every program find a way to effectively train residents to be good physicians and still allow them a personal life?”

Dr. Anson Lee is an Assistant Professor of Cardiac Surgery, Stanford University, Calif.; Training: 4+3 CT Residency, at Washington University, St. Louis.

Ms. Bohlman: “As a physician assistant in cardiac surgery, I represent the reality that physicians with a critical patient population appreciate consistency in their patient management. However, working in a university hospital setting also requires that surgical residents receive appropriate training. With the recently implemented duty restriction hours on resident training programs, advanced practice providers (APPs) have been utilized as an excellent solution for scheduling conflicts without compromising patient care. An example to this point is evident in my own place of work.

Approximately 1 year ago, our surgical intensive care unit transitioned from resident care to a combination of residents and APPs. At that time, the APPs were tasked with the complete care of all cardiac surgery patients. This change reduced the quantity and acuity of patients for which the residents were responsible and therefore allowed for more flexible hours along with a more manageable patient load. These changes, among others, have contributed to improved patient outcomes in the cardiac surgery patient population within our institution. With the increase in APPs that have training in various specialties, there comes an increasing ability to not only fill the gaps in scheduling but to do so with an extension of the providing physician. Although the NEJM article demonstrated no difference in patient outcomes between resident programs with restricted duty hours versus more flexible duty-hour policies, I foresee the future of medicine focusing on trained APPs as a complement to the care that the residents provide.”

Allison Bohlman is a Physician Assistant at Rush University Medical Center in the Integrated cardiovascular thoracic intensive care unit.

Several months ago, Dr. Bilimoria and his colleagues published the long awaited study in NEJM essentially contradicting adverse effects of strict duty hours on patient outcomes (N Engl J Med. 2016 374:713-2). The study, known as the FIRST trial, was published in the March issue of Thoracic Surgery News. Although the study enrolled general surgery residents, its conclusion impacts no specialty more than cardiothoracic surgery, where frequent handoffs complicate tedious perioperative care of sick patients stall learning opportunities for young trainees.

As Dr. Shari Meyerson eloquently noted in her perspective piece for Thoracic Surgery News (March 2016, page 4), surgery training needs to adapt to meet the modern day needs of trainees to rest and spend time with family and friends, with those of exposure to complex clinical scenarios in a short residency period. Arguably, CT surgery trainees are some of the most motivated and driven; to limit their experience on a national level may be shortsighted. On the other hand, appropriate incorporation of advanced practice providers (APPs) may help allay some patient care challenges, free valuable family time, and allow thoracic residents to function well in a more flexible ACGME duty-hour paradigm. To add thoracic relevance to the findings of Dr. Bilimoria and his colleagues, the debate is brought to Thoracic Surgery News by our colleagues from different training pathways below:

Dr. Antonoff: “Due to the timing of my medical school matriculation, I completed my surgical clerkships in the preregulated duty-hour era. I had expectations of what my life would be like as a surgeon when I applied for the general surgery match, and frankly, my expectations prepared me for a life that would revolve around my education, my technical training, and my commitment to patient care. During my years as a junior resident, my surgical training program gradually adapted in recognition of the new guidelines, but it took time. I spent 3 years in the research lab, and, after I came out as a senior resident, I discovered that the rules of the game had totally changed. While duty hours for me, as a senior trainee, were still fairly open, I found that my interns and junior residents had to play by completely new rules. In some ways, on rare occasions, I felt frustrated and resentful of the fact that my duties as a chief resident and thoracic fellow included many of the tasks that I’d done as an intern, because my interns would ‘expire’ after 16 hours. However, much more often, I felt bad for those who came after me.

They seemed desperate to operate, eager to see their patients’ problems through to resolution, and embarrassed to have to end their days earlier than the more senior members of the team. I feel fortunate that I had years of frequent in-house call after long days in the operating room and followed by post-call days of more operating. I finished my junior years without fear of any sick patient in the hospital, I finished my general surgery training without fear of any emergent operation, and I finished my fellowship with confidence that I could get a patient through just about anything if I had access to a cannula.

My early experiences as an attending have certainly kept me humble, and I’ve spent many a night worried about my patients, rethinking choices that I’ve made and stitches that I’ve thrown. But I thank my lucky stars that I was exposed to phenomenal training, and that I had the privilege and opportunity to work the hours needed to reach a reasonable level of safety! I can only imagine that if I’d have spent fewer nights in the hospital, that I’d feel even more anxiety and nausea at this early stage of my surgical career.

As elaborated in the editorial by Dr. Birkmeyer (N Engl J Med. 2016;374:783-4), it is not surprising that patient outcomes did not immediately depend on whether the programs had adhered strictly to the ACGME duty-hour rules. Limited numbers of patients experience critical events during shift change, and hospitals are evolving to function with greater reliance on midlevel practitioners and attending physicians. I would not expect the short-term results of duty-hour flexibility to demonstrate any impact on patient care. However, I do fear that there will be a mid-term impact on trainee accountability and autonomy, which will ultimately impact the competence of the attending surgeons of the future, and downstream potential long-term impact on day-to-day patient outcomes.

As a wife and mother of 3, I recognize that we, as a specialty, need to find ways to support our trainees and their families and to help them live happy lives conducive to functioning outside the hospital. I believe that we can do this with support, mentorship, and advocacy; I do not believe that it requires cutting back on the training that we are all, in the end, so incredibly grateful to receive.”

Dr. Mara Antonoff is an assistant professor of thoracic and cardiovascular surgery at UT MD Anderson Cancer Center. She performed her General Surgery training at the University of Minnesota, 2004-2012, and her Thoracic Surgery Training at Washington University, as a traditional 2-year resident, 2012-2014.

Dr. Stephens: “There is nothing that replaces being bedside. Whether it be a postoperative patient struggling with low cardiac output syndrome overnight, or a patient with a high pressor requirement the etiology of which you are trying to uncover, or a patient you have been following who suddenly arrests, the value of seeing a patient’s trajectory longitudinally is critical to developing clinical acumen. When as an attending I will get called in the middle of the night about a postoperative patient not “doing well,” I will be drawing on my years of being on call and being bedside with my patients.

Patient care is the ultimate goal, and it is clear that overworked residents are at higher risk for making mistakes that jeopardize patient care, which nobody wants. However, the restrictions that duty hours place don’t allow the flexibility necessary for a specialty such as ours, and in fact strict adherence to such regulations inhibits opportunities for our learning. Also concerning is the “shift-work” mentality that seems to be increasingly pervasive with the implementation of duty hours. As has been well documented, and as I have seen personally, the constant patient handoffs that are requisite to implementation of duty hours pose their own perils in terms of patient safety.

Ultimately, these are our patients and we are responsible. Once we are attendings, those responsibilities will not be turned off after we have reached some prespecified hour limit.

The question then remains how best to implement a system across a wide variety of programs that ensures both patient safety and adequate clinical experience in the context of a culture of patient responsibility for the residents. As the NEJM study (N Engl J Med. 2016 374:713-2) shows, flexibility in implementation of duty hours did not result in increased complications, but resulted in improved resident satisfaction in continuity of care and handoffs. In my opinion, this study then encourages specialties such as ours to be more flexible in work hours, to encourage residents when there is a learning opportunity that previously they would be prohibited from taking part in to take hold of that opportunity, and to use this flexibility in implementation of duty hours to combat the invading “shift-work” mentality that will only jeopardize patient care.”

Dr. Elizabeth H. Stephens, MD, PhD is a Cardiothoracic Surgery, resident, PGY4, at Columbia University, New York, as an Integrated I-6 Resident.

Dr. Brown: “I took the traditional 5-year of General Surgery + 2 years of Cardiothoracic Surgery training route to becoming a General Thoracic Surgeon. My General Surgery experience was invaluable to my development as a surgeon. However, after all of those years of General Surgery cases and minimal exposure to Cardiothoracic Surgery cases, coupled with minimal overlap between the two specialties with regard to patient care, I found the learning curve in fellowship to be very steep. I was fortunate to train in a program with phenomenal physician extender support [APPs] in addition to top-notch colleagues in other specialties and excellent nursing, which allowed me to spend the majority of those 2 years in the operating room and completely focused on patient care. During that final phase of training, I welcomed flexibility with regard to the work-hour restrictions to ensure that I was acquiring the experience I needed prior to starting my own practice.”

Lisa M. Brown, MD, MAS, Assistant Professor of Thoracic Surgery, UC Davis Health System, Calif.; Training Institution: Washington University

Dr. Lee: “I started my surgical training in 2005, 2 years after the implementation of the 80-hour workweek restriction. Fortunately for my personal life, my training program took the restriction very seriously and strictly enforced it. As a result, I had scheduled periods off from work, and rarely worked more than 80 hours per week over the course of general surgery. On those occasions that I did, the next weeks, or preceding weeks would be shorter, to compensate. As a product of a 4+3 Thoracic Surgery residency in this environment, the 80-hour workweek extended to my subspecialty training. Our cardiac surgery time strictly enforced the go-home post-call policy. As a result, I believe my duty hours during Thoracic Surgery are likely shorter overall than many other programs.

Everyone hears the rumors of other programs lying about their duty hours. Fortunately, mine was not one of these. Despite this, or because of this, I received top-notch training. At the same time and more importantly, I started a family. I married my wife a week before my internship started, and am still married to the same person. We had two precious daughters during my Thoracic Surgery years. I don’t believe this would have been possible without duty-hours restrictions.

To create an environment where such a task was possible, my program hired an army of mid-level practitioners to deal with the day-to-day tasks of providing cardiothoracic surgical care to the patients, both in the intensive care unit and on the ward.

I rarely had to write a history and physical during Thoracic Surgery training. I consented fewer patients than I have fingers on my hands. I pulled even fewer chest tubes. I can now no longer remember having pulled a central line. I learned these tasks when I was a junior resident. What I did instead as a senior resident was perform over 900 cardiothoracic procedures as the primary surgeon. Now, as an attending surgeon, I still don’t write full histories and physicals by myself. I certainly don’t pull chest tubes and central lines. I consent patients by having a conversation with them, which I did as a resident, but I don’t bring a piece of paper with me in to the clinic room. I have a physician assistant who helps me fill in the gaps.

©Hemera Technologies/Thinkstock

In 8 months of practice, I have performed over 15 thoracic organ transplants, repaired over 15 aortic dissections, half of whom required root replacements, performed more double-valve surgeries than straightforward single-valve replacements, started a minimally invasive atrial fibrillation surgical program, and applied almost every shred of knowledge and experience gained in 3 years of Thoracic Surgery Residency to a busy clinical practice. Most importantly, I continue to come home and watch my two daughters grow up.

With that perspective, I don’t believe the question should be whether or not programs should have the flexibility to enforce or not enforce duty-hours restrictions. It should be, how could every program find a way to effectively train residents to be good physicians and still allow them a personal life?”

Dr. Anson Lee is an Assistant Professor of Cardiac Surgery, Stanford University, Calif.; Training: 4+3 CT Residency, at Washington University, St. Louis.

Ms. Bohlman: “As a physician assistant in cardiac surgery, I represent the reality that physicians with a critical patient population appreciate consistency in their patient management. However, working in a university hospital setting also requires that surgical residents receive appropriate training. With the recently implemented duty restriction hours on resident training programs, advanced practice providers (APPs) have been utilized as an excellent solution for scheduling conflicts without compromising patient care. An example to this point is evident in my own place of work.

Approximately 1 year ago, our surgical intensive care unit transitioned from resident care to a combination of residents and APPs. At that time, the APPs were tasked with the complete care of all cardiac surgery patients. This change reduced the quantity and acuity of patients for which the residents were responsible and therefore allowed for more flexible hours along with a more manageable patient load. These changes, among others, have contributed to improved patient outcomes in the cardiac surgery patient population within our institution. With the increase in APPs that have training in various specialties, there comes an increasing ability to not only fill the gaps in scheduling but to do so with an extension of the providing physician. Although the NEJM article demonstrated no difference in patient outcomes between resident programs with restricted duty hours versus more flexible duty-hour policies, I foresee the future of medicine focusing on trained APPs as a complement to the care that the residents provide.”

Allison Bohlman is a Physician Assistant at Rush University Medical Center in the Integrated cardiovascular thoracic intensive care unit.