Connors Rafe C, Doty John R, Bull David A, May Heidi T, Fullerton David A, Robbins Robert C
University of Utah Affiliated Hospitals, Salt Lake City, UT, USA.
J Thorac Cardiovasc Surg. 2009 Mar;137(3):710-3. doi: 10.1016/j.jtcvs.2008.11.038.
Resident work-hour regulations were instituted to improve patient care during resident training. Although initial data have not shown the intended benefit of limiting resident work hours, concern has developed as to whether resident operative experience has significantly decreased since instituting the work-hour restrictions.
Resident operative logs were reviewed for 3 training institutions in the western United States for residents graduating in the years 1999-2007. Residents were divided into pre-work-hour restriction (1999-2002) and post-work-hour restriction (2003-2007) groups. Thoracic, cardiac, and all combined cases were reviewed separately for all residents at yearly intervals. Statistical analysis was subsequently conducted.
A total of 37 residents were identified from 3 different programs over the study period. Thoracic cases were lower during the first year of training but increased in the second and third years of training after work-hour restrictions (78 vs 42, 65 vs 72, and 102 vs 138; P = .17, P = .59, and P = .11, respectively). Cardiac cases were substantially lower during each year of training after work-hour restrictions (190 vs 153, 154 vs 108, and 116 vs 76; P = 0.15, P < .0001, and P = .001, respectively). Overall total cases were also lower over all years of residency after work-hour restrictions (251 vs 195, 219 vs 187, and 234 vs 214; P = .03, P = .049, and P = .59, respectively).
The overall volume of thoracic surgery cases was not significantly different after the implementation of the 80-hour work-week restriction. The total number of cardiac cases logged was substantially less during the same time period, and therefore as a result, the total number of cases performed after the implementation of the work-hour restrictions was also reduced. Although recent data have not shown an improvement in patient outcomes after restriction of resident work hours, we speculate that in a time of increasingly complex cases, reduction in resident case volumes caused by work-hour restrictions and decreasing cardiac cases might lead to inadequate operative experience.
制定住院医师工作时长规定是为了在住院医师培训期间改善患者护理。尽管初步数据并未显示出限制住院医师工作时长能带来预期的益处，但自实施工作时长限制以来，人们开始担心住院医师的手术经验是否显著减少。
对美国西部3家培训机构1999 - 2007年毕业的住院医师的手术记录进行审查。住院医师被分为工作时长限制前（1999 - 2002年）和工作时长限制后（2003 - 2007年）两组。每年分别对所有住院医师的胸科、心脏科及所有综合病例进行审查。随后进行统计分析。
在研究期间，从3个不同项目中总共确定了37名住院医师。工作时长限制后，培训第一年的胸科病例数较低，但在培训的第二年和第三年有所增加（分别为78例对42例、65例对72例、102例对138例；P = 0.17、P = 0.59、P = 0.11）。工作时长限制后，每年培训期间的心脏科病例数大幅减少（分别为190例对153例、154例对108例、116例对76例；P = 0.15、P < 0.0001、P = 0.001）。工作时长限制后，住院医师培训各年的总体病例数也较低（分别为251例对195例、219例对187例、234例对214例；P = 0.03、P = 0.049、P = 0.59）。
实施每周80小时工作时长限制后，胸外科手术病例的总体数量没有显著差异。同期记录的心脏科病例总数大幅减少，因此，实施工作时长限制后进行的病例总数也减少了。尽管近期数据并未显示出限制住院医师工作时长后患者预后有所改善，但我们推测，在病例日益复杂的时代，工作时长限制导致的住院医师病例量减少以及心脏科病例数下降可能会导致手术经验不足。
