The MD Daily Contract review

September 17, 2018 • By Guest

Should we cap surgeon work hours?


The notion of physician burnout has been discussed in quiet circles for decades, but it is being discussed ever more frequently among medical professionals at large and even in lay publications. Whether it is due to the long hours, increased paperwork, or decreased patient contact, many physicians are admitting they are losing (or have lost) their passion for patient care. Surgeons are perhaps the highest risk for burnout and they often work in high stress situations, for longer shifts than their medicine colleagues.

The plight of surgeons

Surgeons tend to be at the extreme of the physician “burnout” scale with about 40% self-identifying as being burnt out. Perhaps not surprisingly, 30% of surgeons screened positive for depression and 28% had a mental quality of life score below the general population.1 These findings are reproducible for surgeons across the country. General surgeons often have to deal with life and death issues in high stress situations. Stress and threatened burnout have long put surgeons at risk of substance misuse and abuse, especially alcohol abuse.  In addition surgeons may feel pressures to work long hours and operate even after extended overnight call in order to be financially productive.  Surgeons also complain that the loss of autonomy, restriction on their clinical practice secondary to managed care, and increasing malpractice lawsuits weigh heavily on their minds. These stressors add up; up to 15% of surgeons had considered committing suicide in the previous 12 months.

Unlike other specialties, a surgeon’s mistakes can immediately and drastically affects their patients, who are literally under the knife. It is in this setting that the question of work hours arises. Do the long hours affect surgeons such that they must be protected from themselves?  From a public health standpoint, should we cap surgeon work hours to protect patients?

Lessons from residency work hour restrictions

Much of the focus on work hours has come from the literature on residency work hours. Over the past several decades, work hours for physicians in training has decreased secondary to concern about resident wellbeing and patient safety. The American Council for Graduate Medical Education (ACGME) residency work hour restrictions went into effect in 2011, and had a significant effect on the medical community’s view of acceptable physician work hours. The change decreased a call period to 16 hour call (from 24 hours) and limited resident work-hours to a maximum of 80 hours averaged over a four week period.2 While there has been measurable decrease in the number of hours that residents work, the effect on patient safety, resident learning and wellbeing is less clear. Studies across the time periods have revealed contradictory results.2 Fewer hours may not make safer medical care or even happier residents. It seems that we will not find any support for capping surgeon work hours from residency hour restrictions.

What does the research show for surgeons?

While there is convincing evidence of burnout in American surgeons, the relationship between burnout and work hours is not always so clear cut. For example, research shows that major medical errors in surgery are strongly correlated with the surgeon’s self-described sense of burnout and mental quality of life (QOL).3 On the other hand, medical errors do not correlate with the frequency of overnight call or the number of hours worked.3 This would suggest that work hour caps applied to all surgeons would not necessarily reduce medical error. Instead, programs to identify and support struggling surgeons would perhaps be more effective.

What are the guidelines?

The American College of Surgeons (ACS) acknowledges that physicians are at increased risk of burnout, likely secondary to the same characteristics that led them to success as surgeons—a heightened sense of responsibility, perfectionism and commitment to their patients. Unfortunately, the ACS does not  provide any easy answers to the question of physician work hours. Instead, they recognize that surgeons may be “conflicted and unable to make a rational evaluation” as they schedule surgery. Unlike other specialties, surgeons are likely to have been up all night on call and require some rest, but feel that this would be frowned upon by administration and would hurt their bottom line. The ACS suggests a coordinated approach to surgical sleep deprivation, but does not specify the details of this approach. Apparently the solution rests with individual hospitals a surgical practices (that are not incentivized to limit work hours).

So what should a busy surgeon do?

The ACS suggests relying on the professional community—talking to other surgeons, understanding that surgeons are not alone in feeling burnt out, and partnering with the Employee-Physician Assistance program at your hospital or group. Research indicates that efficient and supportive workplaces with hospital leaders who are empathetic and willing to make organizational changes are vital in improving physician wellness.

Surgeons, like all other working professionals, deserve an emphasis on work-life balance. An environment that purports there is no time or need for mental and physical wellbeing can be detrimental to surgeons and increase the already sizeable tension between time spent at work and one’s family and outside pursuits and passions. In fact, surgeons stress that work-life balance, the quality of their spousal relationship, and medical lawsuits are the three major stresses affecting their quality of life1, information the medical community would do well to take notice of.  Individual surgeons, and the surgical specialty as a whole, must resist the “culture of bravado” that suggests individuals must not complain or take personal time, but simply operate and be financially successful.1 In addition, hospital and employee leadership must work to address the problems of the reimbursement system, inadequate administration support, and the scheduling issues that plague surgeons. The importance of healthy surgeon mentors to counsel and guide younger surgeons cannot be overstated.

Here are some concrete steps to prevent burnout:1

  1. Periodically assess your balance—are you at a high, medium or low risk for burnout?
  2. Take personal responsibility and commit to practicing self-care habits
  3. Establish an outlet at work for stress such as a good mentor/support system
  4. Make use of physician assistance programs available in your institution or in subspecialty organizations
  5. Advocate for work-life balance in your institution

While work hour caps are often used as a panacea for physician burnout, they are unlikely to be broadly helpful.  A holistic approach- that looks at number of hours worked as well as physician support and autonomy may be a better model to decrease physician burnout and improve the wellness of both surgeons and patients alike.

References

1. Balch CM, Shanafelt TS. Dynamic Tension between Success in a Surgical Career and Personal Wellness: How Can We Succeed in a Stressful Environment and a “Culture of Bravado”? Ann Surg Oncol. 2011;18(5):1213-1216. doi:10.1245/s10434-011-1629-z

2. Philibert I. What Is Known: Examining the Empirical Literature in Resident Work Hours Using 30 Influential Articles. J Grad Med Educ. 2016;8(5):795-805. doi:10.4300/JGME-D-16-00642.1

3. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and Medical Errors among American Surgeons. Ann Surg. 2010;251(6):995-1000. doi:10.1097/SLA.0b013e3181bfdab3

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