Leading article Surgical training and working time restriction T. B. Glomsaker 1 and K. Søreide 1,2 1 Department of Surgery, Stavanger University Hospital, Postboks 8100, 4068 Stavanger, and 2 Department of Surgical Sciences, University of Bergen, Bergen, Norway (e-mail: tom@glomsaker.no) Published online in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.6595 The global prospect for surgical education is influenced by techni- cal, societal and legislative change. In recent times, clinical innova- tion, improved perioperative care and emerging technologies in other dis- ciplines (such as interventional radi- ology) have changed the indications for surgery. Today, 50–70 per cent of medical students in most West- ern countries are women, which will inevitably influence the surgical work- force as the reproductive years of childbearing overlap those of clini- cal training. In addition, both men and women now appear to care more than their predecessors about lifestyle issues when choosing a career in medicine 1 . Finally, surgical training has been influenced by restriction in working hours. Working time restriction has been enforced by law in Europe and North America, decreasing the time that can be spent training in hospital 2,3 . These regulations are driven by con- cern that fatigued trainees who have been deprived of sleep are prone to increased error when delivering care. In the USA, the Accredita- tion Council for Graduate Medical Education (ACGME) has instituted a national work restriction of 80 h, thereby limiting shift lengths 2 . In a similar fashion, the European Work- ing Time Directive (EWTD) requires the working week for trainees to be limited to 48 h by August 2009. These restrictions will affect both surgical training and the delivery of care in many European countries 3 . This is important for all European nations as there is a flux of surgical staff across borders, especially those of European Union countries. It must be of con- cern that there currently exists no uniform model for the content of sur- gical training. Opponents of working hours restric- tions have highlighted the potential for adverse effects on patient safety, loss of continuity of care, decreased operative volume and reduced clini- cal exposure. An increase in morbid- ity and mortality may be the result. Although the available research does not support these contentions, nei- ther does it support any improvement in quality of care 4 . Despite this, pro- ponents of restricted working time call for even stricter enforcement, as a report by the Institute of Medicine demonstrates 2 . Although it is doubt- ful whether any reliable data exist to support any of the restrictions, including the 80-h working week 4 , much of the rest of society has been regulated in terms of working time for over a century; examples can be found in the Factory Act of 1844 and the Berne Convention of 1905 5 . Fur- thermore, truck drivers and airline pilots have far more restrictive duty hours than surgeons 6 , and surgeons are not immune to the effects of sleep deprivation and unnatural circadian cycles associated with long shifts. It is also true that trainees’ quality of life is improved with shorter hours of duty; they experience a decrease in depression scores and emotional exhaustion, have less risk of motor vehicle accident, have more time with their families, and more time to read 4 . Working hour restrictions cause intense debate and create grave concerns 3–6 . In Scandinavia, a 40- h week was made statutory 30 years ago 7,8 . Although no empirical data justify such a reduction in working hours, on the other hand there are no data pointing to a reduced quality of surgical care in the Scandinavian countries. On the contrary, Scandi- navian countries have been in the forefront of good care in several areas, including cancer surgery and trans- plantation. Some of these results have been obtained through the imple- mentation of national programmes that surgeons actually adhere to – a rather unique situation compared with that found in most other coun- tries. In Norway, training consists of 6 years of general surgery, and most trainees pursue subspecialty training for a further 2–3 years 7 . So surgical training may take 8–10 years. The time frame is even longer before reaching consultant level, and longer still if time is spent in research or on maternity leave during training 7 . To achieve board certification in surgery, mandatory documentation is required of operations performed, of formal supervision, of theoretical and practical courses attended, with examinations, and of a minimum weekly education time at approved education centres 7 . Several courses in basic surgical techniques, simulation and virtual endoscopic/laparoscopic training, and practice on animal models are offered, but so far only a few of these are compulsory. With increased subspecialization, certain requirements have been revised; for instance orthopaedic surgery is no longer part of general surgery training and vice versa 7 . Copyright  2009 British Journal of Surgery Society Ltd British Journal of Surgery 2009; 96: 329–330 Published by John Wiley & Sons Ltd