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Fragmented care: a practicing surgeon's response
  1. Peter J Fabri
  1. Correspondence to Dr Peter J Fabri, Department of Surgery, University of South Florida, 12901 Bruce B. Downs Blvd, Tampa, Florida, USA; pfabri{at}

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Since the introduction of duty hour restrictions by the US Accreditation Council for Graduate Medical Education (ACGME) in 2003, there has been an ongoing debate in the surgical community about the impact on resident education and the quality of patient care.1 ,2 Similar concerns have been raised by surgical educators in European Union nations following the implementation of the European Working Time Directive late in the last century.3 These are not new questions. The term ‘resident’ derives from the fact that in past times, physicians in training actually lived in the hospital and were immediately available to provide care 24 h a day, 7 days a week. One may imagine the concerns when every other night call was instituted (‘You will miss half the good cases!’). Additional expressions of concerns about the quality of care and education were raised when inhouse call was limited to every third night, and later the ACGME implemented, and then further adjusted, common duty hour limits for all specialties. Every time these changes were implemented, surgeons have tried to figure out how to do exactly what they have always done safely, but in fewer hours.

This approach for dealing with reduced hours has served surgical education well in the past. However, the currents limits on duty hours for physicians in training worldwide requires a reframing of the approaches for clinical care, competency attainment and physician education. The models of surgical care and education were established during a time when hospital stays were long, preoperative and postoperative care was provided in the inpatient setting, and the percentage of patients who were severely ill was quite small.4 Major trauma, except in select areas, was less frequent, and often less severe. Many of the complex surgical procedures currently being …

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