At the annual meeting of the New England Surgical Society in Burlington, Vermont, a panel convened to debate the implications of attending surgeon work hour restrictions, presenting experience with work hour restrictions and then presenting arguments for and against their use. The following is a brief Commentary summarizing this discussion.
In the United States, the 2000 Institute of Medicine report, To Err Is Human: Building a Safer Health System, centered the concept of medical errors firmly in the minds of politicians, third-party payers, the national media, and patients. The concept of fatigue causing physicians to err was a central force.1 Although resident training hours have been restricted by the Accreditation Council for Graduate Medical Education since 2003, there is no legislative, board, or American College of Surgeons initiative addressing attending surgeon work hours. In 1998, the European working time directive legislated work hour restrictions for physicians, limiting weekly work hours “on average” to 48 hours, placed limits on night coverage, and delineated mandatory rest periods. Attending surgeon work hour restrictions in Europe resulted in increased specialization, decreased availability of broad-based surgical capabilities, increased difficulty in securing evening and emergency coverage, increased difficulty acquiring critical care and trauma experience, and decreased availability of comprehensive surgical care. Surprisingly, the European working time directive does not apply to overtime and, in fact, 113 000 physicians worked more than 50 million hours of overtime in Germany in 2003, corroborating a notion that European physicians may not be abiding by the restrictions.2