Comment on “A National Survey of Motor Vehicle Crashes Among General Surgical Residents”

To the Editor:

It was with great interest that we read the study “A National Survey of Motor Vehicle Crashes (MVC) Among General Surgical Residents.”¹ In their survey, the authors identified that increases in duty hour violations were associated with an increased in hazardous driving events. The safety and wellbeing of surgical (and all) residents are of paramount importance, and this study clearly identifies a serious issue that has been long known but not widely spoken about. The authors state that to their knowledge this is the first evaluation of the driving habits of surgical residents. While they may be correct that those data have not been published, similar finding were presented by the authors at the Clinical Congress of the American College of Surgeons (ACS) in 1989 (Driving and Residency: An Accident Waiting to Happen, presented at the paper session).

The genesis of that study was several serious MVCs that occurred in 1987 to 1988 to residents in our institution. To ascertain the extent of the issue and identify if it was specialty specific, paper surveys were sent to New Jersey Medical School (NJMS) residents in SURGery, PSYCHiatry, ORTHOpedics, Internal MEDicine, and PEDiatrics (n = 302) as well as all members of the ACS candidate groups from Massachusetts, Illinois, and California (n = 1468). The response rate from our residents varied from 43% (PED) to 63% (SURG) with a mean of 53%. The response rate from the candidate groups was 46% and did not vary by significantly by state.

Over 80% of all NJMS residents reported they were commonly “too tired to drive.” These rates varied from PSYCH (75%) to ORTHO (100%). Eighty-two percent of SURG residents reported falling asleep during their commute, which was statistically greater than any of the other specialties (ORTHO 42%, MED 60%, PED 57%, PSYCH 51%). Thirty-eight percent of all residents reported pulling over at 1 point in their commute to sleep before continuing. Fifty-five percent of those who returned the surveys provided written comments describing MVCs secondary to falling asleep (n = 8), waking up after driving off the road with no MVC (n = 10), missed exits or falling asleep at traffic lights. Similar rates of fatigue were reported in the ACS candidates across all states.

MVC history was obtained in both surveys. There was a statistically significant increase in MVCs from medical school to residency. This is contrary to published data on MVCs decreasing with age and experience. The rate for NJMS residents reporting at least 1 MVC ranged from a high of 27% in MED to a low of 9% for PED. The rate for SURG was 17%.

The issue of difficulty with driving while fatigued was known by all and mentioned in multiple free responses. Contributing issues implicated by the trainees included coverage of multiple hospitals when on call, moonlighting, and a lack of call room space to sleep before leaving the hospital.

One must put these data in perspective of the time (the late 80s) compared with the recent data reported by Schlick et al. While difficult to compare these rates of MVCs and survey results over a 33-year timespan, it does appears that several things have improved. Even in programs that have significant violations in duty hours, the rate of hazardous driving has appeared to decline. Many of the contributing factors identified by the trainees have also been addressed. Our survey data occurred at a time, where many surgical residents were working ≥120 hours/week and call was often every other night. Even residents in “less demanding” specialties worked significantly more than 80 hours per week with few or no days off. Attempts to impose duty hour restrictions were at their infancy beginning in New York in 1989.² These restrictions were decried by many national organizations, and the ACGME did not adopt formal duty hour restrictions until 2003. Due to a lack of compliance, these were further strengthened in 2011. The questioning the senior author received at the time of the presentation reflected these sentiments. Finally, resident wellness was not in the lexicon nor ever considered.

On the positive side, auto safety has increased markedly with fewer MVC occupant injuries that provide increased safety to fatigued trainees. Also, our survey occurred when cell phones did not exist and the problems of texting and distracted driving were less significant factors. Something not considered in the current study. Furthermore, while the study on Schlick et al focuses on duty hour violation, it still remains inconceivable to the public that an 80-hour work week is acceptable. Other issues not considered by the authors are the effect of changeable shift work schedules and the inevitable “crash” and fatigue that occurs after a period of intense concentration and activity (eg, being on call).

As with many academic careers, there are studies and lines of investigations that one regrets not pursing further. In hindsight, it is truly unfortunate that our data were never attempted to be published. When these data were presented, the senior author (DHL) was a first-year attending. Based on the response of the audience at the ACS meeting, the advice of mentors and concern for its effect on career advancement, we decided to self-censor the work. This was clearly a mistake which we are, albeit far too late, rectifying. One can only imagine (or hope) that these data may have helped push the changes in duty hours to address resident fatigue and resident wellness earlier than what ultimately transpired. Thankfully, it is now finally seeing the light of day and will hopefully provide an historical context to the paper by Schlick et al, which demonstrates, while things may be better, there is still a long way to go.