Con: Shift work surgery: Loss of continuity or sensible balance of responsibility?

The decision to support resident duty-hour restrictions and transition to shift work have been significant topics of debate in modern medicine. In surgery, the debate has taken on particular significance, as the field has characteristically embodied long hours as well as physical and mental strain in the pursuit of technical excellence. While shift work and duty-hour restrictions make sense in certain environments, they should not be blindly applied to all medical specialties—especially surgery. Surgery adds a unique dimension to patient care in that surgical care takes place over a continuum and provides unique opportunities for trainees to learn and practice acute perioperative medicine. Here, I aim to provide evidence generally supporting the maintenance of longer hours instead of shift work surgery, with the immediate caveats that first, not all surgery programs are similarly structured, and second, not all programs receive the same case volumes.

Interference with resident education

A surgical trainee’s responsibilities and education do not simply end at the conclusion of a case. The immediate postoperative period is one of high activity and interest for surgeons and trainees; this period often shapes a patient’s long-term outcome and sets the tone for the relationship between health care professionals and their patients. Many complications (such as myocardial infarction and chest pain, hypotension, arrhythmia, respiratory anomalies, and bleeding) often present themselves within the first 48 hours after an operation.1,2 From a training standpoint, it is imperative that budding surgeons familiarize themselves with the presentation and management of such outcomes, as this experience can directly affect pre- and intraoperative maneuvers in future cases.

With shift work, this critical period of care time is interrupted, thereby affecting learning and synthesis. The emotional pendulum has swung back and forth on the issue, but numerous quality and safety articles have suggested that longer hours do not diminish patient safety or education.3-5

In fact, the opposite may be true. Early data had suggested that case volume per resident remained unchanged or even increased in a shift work environment;6 however, the latest data from Europe actually demonstrate reductions by as much as 13 percent for traumatic cases and up to 32 percent for elective procedures.7 Moreover, in one setting, surgeon performance on in-service exams actually decreased after regulations were put in place, although more studies are needed to validate this finding.8

Personal tolls

The aim of this article is not to malign shift work, but rather to emphasize that it has been used broadly without consideration of the ancillary factors that promote or encumber seamless care.

Surgical residencies are notorious for physical and mental strain, and sleep deprivation is a prevalent consequence. Yet, while shift work sought to provide residents with a predictable schedule and more personal time for recovery—both of which are favorable—the manner in which shifts are scheduled is directly dependent on the preferences of the scheduler. Anecdotally, many programs establish shifts based on seniority, with senior residents receiving a more predictable schedule and juniors being scheduled to fill in any remaining gaps in coverage.

Therefore, the end result for many trainees is often a shift schedule that arbitrarily peppers night shifts suboptimally. For residents transitioning from a period of day shifts to nights, the seemingly random insertion of nights without factoring in an adequate adjustment time ends up propagating insomnia, circadian misalignment, and melatonin suppression, which, in turn, promotes an abnormal routine, nutritional problems, and exposes residents to the very issues that shift work sought to mitigate in the first place.9-11 Some of the most tangible shortcomings of the shift system also rear their heads at night, including workload imbalance, a decrease in resources, and emotional isolation.

Effects on colleagues and patients

Shift work also calls attention to a general increase in midlevel support, as well as continued shortcomings with communication. Many surgical departments around the country have employed physician assistants (PAs), most of whom actively manage floor patients and many of whom assist to a significant degree in the operating room. Because PAs reduce resident workload and facilitate an increase in overall surgical volume, they fill a crucial role in modern health care delivery and ultimately allow residents to pursue an educational agenda with greater freedom and focus.12 To have residents adopt the shift work schedule that midlevels use would certainly hamper such benefits.

With respect to communication, the quality of a given patient’s course becomes significantly more dependent on a higher quality handoff between residents. While recent efforts have sought to improve and standardize this process, handoffs are still variable, carry a degree of subjectivity, and are prone to errors and omissions that can complicate patient care.13-15 With a shift-based system, the number of such handoffs proportionately increases and can set the stage for error propagation.

The aim of this article is not to malign shift work, but rather to emphasize that it has been used broadly without consideration of the ancillary factors that promote or encumber seamless care. It is a system of practice that actually makes a lot of sense in fields naturally espousing little to no long-term critical care—particularly emergency medicine, radiology, and physical medicine, to name a few. However, in fields that often have complex patients necessitating inpatient care for periods of time—internal medicine and surgery most classically—the value of a shift system becomes increasingly questionable.


References

  1. Thompson JS, Baxter BT, Allison JG, Johnson FE, Lee KK, Park WY. Temporal patterns of postoperative complications. Arch Surg. 2003; 138(6):596-602.
  2. Mulholland MW, Doherty GM. Complications in Surgery. Philadelphia, PA. Lippincott Williams & Wilkins, 2012.
  3. Rajaram R, Chung JW, Jones AT, et al. Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance. JAMA. 2014; 312(22):2374-2384.
  4. Rajaram R, Saadat L, Chung J, Dahlke A, Yang AD, Odell DD, Bilimoria KY. Impact of the 2011 ACGME resident duty hour reform on hospital patient experience and processes-of-care. BMJ Qual Saf. 2016;25(12):962-970.
  5. Fletcher KE, Ranji SR. Does it matter how much physician trainees work anymore? BMJ Qual Saf. 2016;25(12):914-916.
  6. Kohlbrenner A, Dirks R, Davis J, Wolfe M, Maser C. Of duty hour violations and shift work: Changing the educational paradigm. Am J Surg. 2016;211(6):1164-1168.
  7. Sevenoaks H, Ajwani S, Hujazi I, Sergeant J, Woodruff M, Barrie J, Mehta J. Shift working reduces operative experience for trauma and orthopaedic higher surgical trainees: A UK multicentre study. Ann R Coll Surg Engl. 2019;101(3):197-202.
  8. Jagannathan J, Vates GE, Pouratian N, Sheehan JP, Patrie J, Grady MS, Jane JA. Impact of the Accreditation Council for Graduate Medical Education work-hour regulations on neurosurgical resident education and productivity. J Neurosurg. 2009;110(5):820-827.
  9. Smith MR. Eastman, CI. Shift work: Health, performance and safety problems, traditional countermeasures, and innovative management strategies to reduce circadian misalignment. Nat Sci Sleep. 2012;110(5):111-132.
  10. Amirian I, Andersen LT, Rosenberg J, Gogenur I. Working night shifts affects surgeons’ biological rhythm. Am J Surg. 2015;210(2):389-395.
  11. Mota MC, Waterhouse J, De-Souza DA, et al. Sleep pattern is associated with adipokine levels and nutritional markers in resident physicians. Chronobiol Int. 2014;31(10):1130-1138.
  12. Dies N, Rashid S, Shandling M, Swallow C, Easson AM, Kennedy E. Physician assistants reduce resident workload and improve care in an academic surgical setting. JAAPA. 2016;29(2:41-46.
  13. Hart T, Samways JW, Kukendrarajah K, Keenan M, Chaudhri S. Improving out-of-hours surgical patient care. Int J Health Care Qual Assur. 2018;31(7):845-854.
  14. Karamchandani K, Fitzgerald K, Carroll D, et al. A multidisciplinary handoff process to standardize the transfer of care between the intensive care unit and the operating room. Qual Manag Health Care. 2018;27(4):215-222.
  15. Friend K, Hook L, Joshi ART. Improving information transfer during transitions of care via standardized handoffs. Am Surg. 2018;84(7):1169-1174.

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