The 10,000-hour rule

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In 2002, the Accreditation Council for Graduate Medical Education, or ACGME, rocked traditional residency training paradigms by proposing a regulated residency call schedule.1 Revised standards were implemented in 2011 throughout the United States prohibiting first-year residents from spending more than 16 consecutive hours in the hospital and restricting senior residents from working more than 80 hr/week averaged over the month.2 In Canada, there is no national agreement on residency restriction hours; however, in 2011, the province of Quebec mandated that 24-hour in-hospital call represents a violation of Canadian Charter of Rights and Freedoms and implemented a 16-hour call duty schedule for all Quebec trainees.3

JAMA recently published two observational cohort studies that included over 2 million hospitalized adults across the United States from 2009 to 2012.4,5 Patient outcomes (including 30-day mortality and readmissions) were compared before the 2011 reforms in duty hours and after 2011.

The key finding from these studies, albeit from a retrospective observational standpoint, demonstrated that even with the introduction of resident restriction duty hours there has been no effect on these patient outcomes. The authors wrote that such an observational study lacks the power to produce the highest level of scientific evidence that will guide practice and policy decisions. But it remains astonishing, that without any evidence in place to support, inform, or implement decisions, a change to the entire paradigm of residency training was made despite the considerable time, effort, and cost involved in implementation of these actions.

Unfortunately, the implementation of these guidelines puts evidence-based medicine to shame.

Now, after a few years of integrating these duty-hour reforms, the observational and longitudinal evidence has failed to demonstrate improved patient safety. If the primary goal was to demonstrate that the imposition of duty-hour restriction would improve patient safety, it has been unsuccessful to date.

Putting the debate aside, we currently work and live in an era of restricted resident duty hours. Looking ahead 10-15 years, we have to question what type of physicians we will be with the current duty-hour restrictions in place, and then reflect on the type of physicians we want and strive to be.

Especially in surgical residency training programs, the overarching goal is for programs to train a safe, competent, and independent surgeon within 5 years. With the current work-hour restrictions, I am not confident this can be achieved.

Many eloquent debates have been written on lack of patient ownership, professionalism, and clinical judgment in our current training paradigm that I won’t belabor. Malcolm Gladwell’s book “Outliers” repeatedly mentioned the “10,000-hour rule” and the principle holds that 10,000 hours of “deliberate practice” are needed to become world-class in any field.

This speaks volumes to surgical trainees who will be required to master complex technical skills and even more multifaceted appropriate judgments, which I doubt can be achieved in the current work-hour restrictions. I am from the camp that if we remain in our present work-hour restriction schedules, there will be a need to modify training to conform to these duty-hour restrictions in order to prepare residents optimally for practice.

Perhaps moving toward a competency-based curriculum would ensure that a surgical trainee is in fact, safe and proficient and ready to transition into practice.

So we now find ourselves working backward trying to validate the system we are presently working in. To that effect, a multicenter randomized controlled trial (The Flexibility in Duty Hour Requirements for Surgical Trainees trial) is underway with study end date projected for June 2015.

FIRST aims to determine if increasing flexibility of surgical resident duty-hour requirements affects patient care, surgical outcomes, and resident perceptions. Hospitals or programs will be randomized to either an intervention group with flexibility of duty-hour restrictions with the elimination of current duty-hour requirements or a control group with continued adherence to current requirements.

I cannot foresee what the future may hold, but I will continue to strive for excellence and hope that when my time comes to transition from trainee into independent practice, I will be ready.

References

1. JAMA 2002;288:1112-4.

2. ACGME Duty Hours. Accreditation Council for Graduate Medical Education, 2014 (www.acgme.org/acgmeweb/tabid/271/GraduateMedicalEducation/DutyHours.aspx).

3. Towards a Pan-Canadian Consensus on Resident Duty Hours. Royal College of Physicians and Surgeons of Canada, 2014 (www.royalcollege.ca/portal/page/portal/rc/advocacy/educational_initiatives/resident_duty_hours).

4. JAMA 2014;312:2364-73.5. JAMA 2014;312:2374-84.

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