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I am forced to write anonymously because of gross neglect by my residency program regarding standard ACGME duty-hour rules. If my name were published, it would identify my program.

As a PGY-2, I worked 100+ hours per week on average last year while taking primary call for my urology department. (Admittedly, the PGY-2 is the historic “worst year” for any urology resident.) On a quarterly basis (depending on manpower), we take long call and routinely put in 30 to 36-hour shifts. At one point last year, I worked 42 straight days in the hospital without a day off — while my unlucky co-resident hit 56 straight days at one point. Every week, I submitted the exact same erroneous work hours, reflecting that I worked six consecutive 13-hour days and had Sunday off, for 78 hours total. With this, I want to be clear: I am not writing to complain about my hours. Instead, I am writing to complain about the fact that my surgical training is still poor despite putting in “old-school” hours.

In my opinion, improvements in surgical training are limited because of our unceasing focus on resident duty-hour rules. Urology is an interesting case study in relation to the effect of duty-hour restrictions on surgical training. As common practice, many urology residencies are exempt from standard duty-hour rules because of an ACGME provision under which residents take “home call.”

Essentially, time spent covering the call pager does not count towards duty rules if the resident is able to cover the pager from home. That said, I just finished my PGY-2 year in a busy urology residency that is representative of many others around the country, and while we claim “home-call,” I took 96 calls last year and went home exactly six times on a few particularly slow weekend nights. Otherwise, our on-call resident is lucky to get 2 hours of interrupted sleep, and then a full day starts again with 5:45 a.m. rounds. “Post-call” days, which have become common in most residencies, are foreign to us.

Despite these hours, I still think my surgical preparation is poor relative to that of residents in my position 15 to 20 years ago. Below are a few reflections on issues that provide major barriers to surgical training, yet have no relation to duty-hours. My attendings (many of whom are unaware our programs ignores duty-hour rules) quickly cite duty-hours as the #1 source of my generation’s surgical inadequacies.

However, our hours are likely similar to those of “old-school” trainees. Further, urology residents were never building the bulk of their surgical chops on middle-of-the-night emergency cases; it just isn’t that type of specialty. So why is my generation of urologists still so poorly prepared? Below are some reflections:

1. Lack of operative autonomy. The days of free-wheeling at the VA are over. Medicine has become much more risk-averse than it was years ago, and as a result, residents today simply do not get the same level of autonomy that previous generations received. Many readers will likely be quick to say that this generation never earns that autonomy, but I hope they will temper these thoughts. Even the most skilled chief resident today — the guy who makes everyone else jealous with his natural skills — rarely is given the opportunity to operate independently.

Veterans Administration rules regarding attending presence/participation in cases have become strict, and while it used to be common practice for senior attendings to run two operating rooms simultaneously, this has become rare today and will probably soon be obsolete with future patient safety and billing restrictions. For a senior resident, few experiences force growth in skill and confidence quite like operating independently. However, these opportunities for independence are becoming exceedingly rare.

2. Changing utilization of resident labor. My operative case log through intern year and my PGY-2 urology year were weak. As a general surgery intern, I was lucky to get in the OR for even a couple cases per week. Even when I transitioned to my PGY-2 urology year, I still only got in the OR for 1 to 2 days per week on average. What was I doing? I was covering attendings’ outpatient clinics. It is no secret that outpatient volumes have grown tremendously over the years, and perhaps more notable, documentation and administrative demands have exploded. In my program, it is standard practice for attendings to have coverage from a junior resident plus a physician assistant for every clinic. At the end of clinic, all notes are complete and require only a minimal attending attestation and signature prior to heading home for the day. This really creates a dream situation for our attendings relative to the experience in private practice; however, opportunities for learning reach a quick plateau for the junior resident seeing postop patients in clinic three days per week.

3. Lack of feedback/critical approach to improvement. Medical residents receive notably poor feedback from attendings. We are yelled at frequently. We frequently have surgical instruments yanked out of our hands if we aren’t doing a procedure up to expectations. However, rarely are we given meaningful, structured feedback or instruction. In surgical residency, naturally skilled residents are given the reigns from attendings because they can advance more quickly through a case than an unskilled resident. Meanwhile, unskilled residents are often given no chance at all to lead a dissection. As a result, the rich get richer, and the poor get poorer. I truly believe this lack of meaningful feedback and evaluation starts in medical school, and as a result, residency programs have no realistic way of identifying naturally skilled surgeons as it relates to speed and dexterity. Residents need to understand clearly where strengths and weakness lie so that they can make targeted efforts at improvement.

Again, I hope this helps advance a more critical look at aspects of surgical training that are unrelated to work hours. I expect that the debate around work-hours will continue, but we cannot allow our tunnel vision to stymie progress in other aspects of training.

The author is an anonymous physician.

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