Wednesday, April 7th 2010

Do We Need An ACGSE?

There’s been a lot of dissatisfaction in surgical training with work hour restrictions. Perhaps I shouldn’t limit it to surgical residencies, merely to say, instead, that they’ve been the most vocal for my experience.

The 80 hour work week and the 30 hour work shift restrictions have been bemoaned by academic surgeons. Fears that resident’s hand offs of patients would harm continuity of care and thus patient outcomes were front and center, and voiced by all specialties. Fears that resident surgeons would get less hands on surgical experience were unique to surgery but no less concerning.

Talk that further restrictions on how much residents can work are coming brings the issue front and center again. A not too distant IOM report commissioned by the AHRQ recommended such further limitations on resident work hours. And decried by surgical specialists and others alike. I’ve heard prominent individuals from within organized surgery, of course being explicit that they’re voicing their opinions as individuals, decry any further attempt to limit the surgical resident experience.

The surgical specialties are poorly represented in the decision making process. The IOM committee which so recently commented on resident work hours had a single surgical subspecialists on it. The current ACGME Board of Directors has two surgeons sitting on it (and I’m explicitly excluding the ophthalmologists serving on it, and for reason I believe considering their training experience as compared to say that of an orthopedic surgeon). That is two representatives out of thirty or 6% of the vote on the body that will ultimately, at present, determine any further resident work hour restrictions.

With relatively broad coverage in the media of the issue, a decided bent in the public for support of work hour restrictions, and significant public advocacy money in play to influence the decision the whispers from within the ACGME are that further restrictions are inevitable in the next 2 years.

But what if the decision was taken out of the hands of the ACGME, at least for surgical residencies?

There is a growing movement amongst rather prominent academic surgeons for an Accreditation Council for Graduate Surgical Education. Organizing such would be no small feat. Getting the state boards, with public pressure in favor of restrictions, to recognize it may be even more of a hurdle. And that presumes that the inevitability of all of this mess isn’t Congress legislating resident work hours as say the Patient and Physician Protection and Safety Act [PDF] tried to do early last decade.

It’s true, work hour restrictions have worked the rest of the world over. European registars are limited to 48 hours a week and it is hard to demonstrate a qualitative difference between a CABG here and over there. And while the design of their health care system necessitates that many of them will spend years as SHOs (or even lower on the training pole) before a consultant spot opens up.

Drawing the analogy with other other surgical training experiences across the world would require a reimagining of how health care is organized in America. A more tertiary experience with fewer surgeons and lengthier training with further graduation of responsibility during it. That’s not something I’m personally willing to accept. As much as residents still bemoan their hours in the hospital, if push came to shove, and an ACGSE could postpone further reductions in my operative experience I am all for it.