Invited commentaries

Dr. Steven Howard made several excellent points in his grand rounds presentation to the Department of Surgery. Since the work hour limits have been implemented, the general surgery residents at Baylor University Medical Center in Dallas seem to have adjusted very well and favor the reduced work hours. Case volumes performed by general surgery residents have not decreased significantly, as might have been expected.

In the past 6 to 7 years, applications to surgery residency programs had been decreasing. That trend changed. With the implementation of the new work hour limits, the number of applications to the general surgery residency program at Baylor increased by 40%. More women are graduating from medical school as well. For the past 2 years, the number of female applicants applying to our general surgery residency program has been 30%. Thus, male applicants outnumber female applicants 2.3 to 1.

The limitation of work hours, although helpful, does not solve the fatigue issue: even with call every fourth night, residents can be in the hospital for 30 hours and theoretically be awake for 30 continuous hours. The residents seem to become sleepier around 4:00 to 5:00 AM and then get a resurgence of energy when they would normally awaken from a full night's sleep.

Dr. Howard and others have demonstrated that residents have episodes of micro sleep with considerable fatigue and are never aware that they have momentarily lapsed into sleep. This has significant implications when residents are driving home or to another location following prolonged sleep deprivation. A recent Web-based study indicated that 2737 residents who were sleep deprived had significantly more automobile accidents than individuals who were not sleep deprived. The monthly risk of an automobile crash increased by 9%. The monthly risk for a crash during commute from work increased by 16.24% (1).

As Dr. Howard indicated, institutions need to develop comprehensive fatigue management plans, including having sleep areas available for residents before they drive home if they choose to utilize such facilities. It may become apparent that in addition to limited work hours, work shifts may need to be limited to something less than the current 24 to 30 hours. This has been done by paramedical personnel, including nurses, for decades.

According to the common program requirements of the Accreditation Council for Graduate Medical Education (2), duty hours are defined as all clinical activities related to the residency program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in house during call activities, and scheduled academic activities such as conferences. Duty hours do not include reading and preparation time spent away from the hospital. Duty hours must be limited to 80 hours per week, averaged over a 4-week period, inclusive of all in-house call activities.

Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities. Adequate time for rest and personal activities must be provided. This shall consist of a 10-hour time period provided between all daily duty periods and after in-house call. In-house call is defined as those duty hours beyond the normal work day when residents are required to be immediately available in the assigned institution.

Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to 6 additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care. No new patients may be accepted after 24 continuous hours on duty. A new patient is defined as any patient for whom the resident has not previously provided care or the department has not provided care.

At-home call is defined as call taken from outside the assigned institution. The frequency of at-home call is not subject to the every third night limitation. However, it must not be so frequent as to preclude rest and reasonable personal time for each resident. Residents taking at-home call must be provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period. When residents are called into the hospital from home, the hours residents spend in house are counted toward the 80-hour limit.