t h e s u r g e o n 9 ( 2 0 1 1 ) S 8 eS 9

available at www.sciencedirect.com

The Surgeon, Journal of the Royal Colleges

of Surgeons of Edinburgh and Ireland
www.thesurgeon.net

Review

The impact of reduced working hours on surgical training

in Australia and New Zealand

Ian R. Gough
Royal Australasian College of Surgeons, Spring Street, Melbourne, Australia

article info abstract

Article history: There is a worldwide trend for reduced working hours for doctors, particularly in the
Received 22 October 2010 developed western countries. This has been led by the introduction of the European
Accepted 3 November 2010 Working Time Directive (EWTD) that has had a significant impact on work patterns and
training. Australia currently has a more flexible working environment but this is changing.
In New Zealand there is a contract for resident doctors defining a maximum 72 h of ros-
Keywords: tered work per week.
Surgical ª 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and
Training Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Working
Hours

Working hours of surgical trainees in Australia
and New Zealand
There is a worldwide trend for reduced working hours for
doctors, particularly in the developed western countries. This
has been led by the introduction of the European Working
Time Directive (EWTD) that has had a significant impact on
work patterns and training.
Australia currently has a more flexible working environ-
ment but this is changing. In New Zealand there is a contract
for resident doctors defining a maximum 72 h of rostered work
per week.
The Royal Australasian College of Surgeons Trainees
Association (RACSTA) conducted an online survey of trainees
concerning fatigue and related matters. There were 659
responses representing 55% of eligible participants. Surgical
trainees work long hours although most consider them
reasonable to accomplish the clinical work and their training
requirements.
Fifty hours or more per week are worked by 94% of
surgical trainees, 60 h or more by 61%, 70 h or more by 25%
and 80 h or more by 8%. Eighty four percent had worked
shifts more than 12 h and 75% had been rostered on call for
24 h. The working hours were considered insufficient for
training by 17%, about right by 66% and excessive by 17%.
Support for maximum regulated working hours was mixed e
with 34% opposed, 20% neutral and 46% in favour. A
reasonable upper limit of working hours was thought to be 50
or less by 16%, 55 by 15%, 60 by 26%, 65 by 12%, 70 by 10%, 75
by 4% and 80 or more by 12%, with others not expressing an
opinion.
Effect of fatigue on surgeon performance and
surgical outcomes
The Royal Australasian College of Surgeons (RACS) has
a position on safe working hours which recognises that

E-mail address: ian.gough@surgeons.org.

1479-666X/$ e see front matter ª 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of
Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.surge.2010.11.010
 t h e s u r g e o n 9 ( 2 0 1 1 ) S 8 eS 9
a balance should be found between reasonable hours that
avoid excessive fatigue and the requirements of patient safety
by achieving effective handover of care to ensure continuity of
patient care. Recently, the Australian Safety and Efficacy
Register of New Interventional Procedures-Surgical (ASERNIP-
S), e a research unit within the RACS, conducted an evidence
based systematic review of the effect of fatigue on surgeon
performance and surgical outcomes. The conclusions were
that the evidence base was relatively weak and many studies
relied on surrogate measures rather than actual surgical
performance outcomes. There is a need for more research in
this field, particularly to determine whether surgeons and
trainees are able to adapt when fatigued and thereby avoid
adverse patient outcomes.
New Zealand resident doctors working hours
In New Zealand there is an agreement that defines the ordi-
nary hours of work as 40 h per week and not more than 8 h per
day, with normal work rostered between 7.30 am and 5.30 pm
Monday to Friday. Overtime is permitted and paid. On-call is
additional and protected training time is included. There
should be a minimum break of 8 h between any 2 rostered
periods of duty. A resident doctor cannot be required to work
more than 16 h in any 24 h or more than 72 h in any 7-day
period, but if the doctor agrees to work there are penalty
payments.
Regulation of working hours in Queensland
Despite a variety of opinions regarding the hours of work that
constitute a threshold for impaired performance, there is
a strong trend for reduced hours by regulation. In Queensland,
one of Australia’s 6 States, a tragic death of a patient triggered
significant legislative change. There is now a Medical Officers’
(Queensland Health) Certified Agreement (No. 2) 2009. This
establishes a normal working week of 38 h e defined as
actually working in the hospital, not including on-call. Shifts
are for a maximum of 12 h. Overtime is allowable and payable
and there is no maximum number of hours defined.
As in New Zealand, in Queensland and other Australian
jurisdictions there are no guidelines for activities that are
permitted outside the hours of rostered work. This means that
educational activities are allowed, in contrast to the European
Working Time Directive.
Surgical training in Australia and New Zealand
The RACS introduced a new Surgical Education and Training
program (SET) in 2008. This takes 5 years for 6 of our special-
ties and 6 years for the other three. The SET program is
competency based, with regular in-training assessments and
skills courses. There are multiple challenges in delivering
S9
a comprehensive training in a shorter time, so competency
milestones are essential. The RACS has identified 9 compe-
tencies that encompass the essential roles of a surgeon and
the learning and assessment of these is embedded in the SET
program. The clinical rotations must be organised to cover the
curriculum in the time available and the clinical experiences
must be optimised. There have been problems in our public
hospitals having to manage a large emergency case-load and
this has had a negative impact on planned elective surgery.
There have also been funding constraints and industrial
issues for all healthcare workers (of which reduced working
hours is an important aspect) that have combined to reduce
the availability of direct operative experience. The case-mix in
our public hospitals is limited in some specialties and it is now
necessary to expand our training into the private sector to
ensure a broad training experience. This expansion is impor-
tant in Australia, where approximately 60% of elective surgery
takes place in private hospitals. In addition, we are increas-
ingly utilising simulated training to supplement and fast-track
learning experiences.
To assist in meeting the challenges of SET the RACS has
established an Academy of Surgical Educators. The College
Dean of Education leads this group of Fellows and staff who
together form a resource to ensure that the educational
objectives of the SET program and the continuing professional
development needs of Fellows are met in a professional way.
We are focussing on surgical education as a discipline and an
activity that we hope will be increasingly taken up by
surgeons as part of their regular practice.
Conclusions
Limited working hours create challenges for patient care and
for training. They are a reality and we must adapt to the
regulatory requirements by creative rostering and innovative
educational programs.
Safety and efficiency in clinical care requires a change from
the traditional paradigm of personal responsibility for conti-
nuity of care and an acceptance of team-based care with
robust safe handover between team members.
Limited hours of clinical exposure have significant poten-
tial to weaken surgical training. Our response should not be to
increase the years of training to match the numbers previ-
ously thought necessary to train a surgeon. Instead, we
should strive to train efficiently and, if possible, in a shorter
time. This is a huge challenge and the solutions, at least in
part, are likely to include a combination of courses and
simulations achieving defined competencies through a struc-
tured curriculum.
Conflict of interest
None declared.