Does the introduction of duty-hour restriction in the United States negatively affect the operative volume of surgical trainees?

Over the last few years, both sides of the North Atlantic have witnessed compulsory duty-hour restrictions for doctors. It has been suggested that the reduction in working hours for surgeons in training may have a negative impact on their exposure to surgical procedures and therefore, on the quality of training. A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: among surgeons enrolled in a training program, does the introduction of duty-hour restrictions have a negative impact on their exposure to surgical procedures and therefore, on the quality of training? In total, more than 74 papers were found using the reported search, of which 15 represented the best evidence to answer the question. All these manuscripts came from the USA. The authors, journal, date and country of publication, group studied, study type, relevant outcomes and results of these papers are tabulated. Studies from different surgical disciplines, such as general, orthopedic, pediatric, cardiothoracic and vascular surgery were included. Among the studies analysed, eight revealed a decrease, five showed no change, and two studies demonstrated an increase in the operative experience of residents following the introduction of the 80-hour limit. The changes appear to have more negatively affected junior residents in favor of more senior ones due to a shift in the surgical workload to the latter. Interestingly, some studies demonstrated better results in the in-training examinations (testing for clinical and basic science knowledge) following the duty-hour restrictions. We conclude that although most of the studies included in this review revealed that the introduction of working-hour restrictions in the USA has produced a decrease in number of cases performed by trainees, some have failed to do so. Changes in the residents' working patterns, such as 'night float' and 'leave early' models, may be useful to preserve exposure to surgical procedures.