Neurosurgeons Analyze Potential Impact of Resident Work Hour Changes

CHARLOTTESVILLE, VA - Two insightful articles published in the May 2009 Journal of Neurosurgery present candid and in-depth analyses of the potential effects further resident work-hour reductions may have on patient safety and the practice of neurosurgery. The articles also explore the effects of the July

2003 reduction in resident work hours, as instituted by the Accreditation Council on Graduate Medical Education (ACGME). The articles are posted on the JNSPG Web site at http://thejns.org/toc/jns/current.

"Resident duty hour regulation and patient safety: establishing a balance between concerns about resident fatigue and adequate training in neurosurgery" is authored by M. Sean Grady, MD, Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia. Co- authors are H. Hunt Batjer, MD, FACS, and Ralph G. Dacey Jr., MD. This article reflects the opinions of the three major neurosurgical organizations primarily involved in neurosurgical resident education: the Society of Neurological Surgeons (SNS), the American Board of Neurological Surgery (ABNS), and the Residency Review Committee for Neurological Surgery.

A companion article, "Impact of the Accreditation Council for Graduate Medical Education work-hour regulations on neurosurgical resident education and productivity" is authored by Jay Jagannathan, MD, University of Virginia

(UVA) Health Sciences Center, Charlottesville. Co-authors are Dr. Grady, G.

Edward Vates, MD, PhD, Nader Pouratian, MD, PhD, Jason P. Sheehan, MD, PhD, James Patrie, MS, and John A. Jane Sr., MD, PhD. This article presents the resident viewpoint, citing measurable data from the UVA and SNS; the ACGME-accredited neurological residency program survey; ABNS written examination scores; and resident academic productivity.

"For the last 10 years, postgraduate training in medicine has been under scrutiny, with studies citing concerns about resident fatigue and patient safety. Numerous adjustments were made by neurosurgical educators six years ago when the ACGME instituted the maximum 24-hour shift length and 80-hour resident work week. And while our specialty embraced these changes, we are very concerned about the patient safety implications if resident work hours are further reduced. These concerns include serious risks associated with too many patient handoffs; a lack of continuity of care in complex neurosurgical disease or injury cases; and the creation of a new generation of neurosurgeons with reduced surgical experience/expertise due to less exposure to complex surgical cases and direct patient care," remarked Dr. Grady. "On this last point, the ultimate effects of an 80-hour work week on neurosurgical education and surgical training will probably not be completely understood until the first group of trainees under the current system have completed their training and entered practice. Thus, it is ill- advised to implement further reductions until the effects of the current rules have been fully measured."

The neurological residency program survey provided some insightful opinions from residency program directors and residents:

  • The majority of chief residents and residency program directors believed that the 80-hour work week had compromised resident training (96 percent) and decreased surgical experience (98 percent).
  • Most chief residents and residency program directors believed that the work- hour regulations negatively affected patient safety (78 versus 96 percent) and access to quality care (87 versus 82 percent), respectively.
  • All residency program directors and most chief residents (98 percent) believed that a decrease to 56 work hours would further compromise resident training and surgical education.

The Institute of Medicine recently proposed reducing resident work hours to a maximum 16-hour shift length, and others are advocating further reductions in the work week, perhaps not to exceed 56 hours, as is the case in Great Britain. "Clearly, resident fatigue has the potential to cause adverse patient outcomes, but these proposals could easily result in far worse repercussions for patients," said Dr. Grady.

A one-size-fits-all approach to resident duty hours - which assume that all areas of medicine have similar demands and that all resident physicians have a similar set of interests, skills, and endurance - does not account for the unique characteristics required for success in specific areas of medicine.

Neurosurgical training is among the lengthiest, requiring a minimum of six years after medical school, with the expectation that residents master the most complex system in the human body. Neurosurgical residents must acquire extensive knowledge and experience in treating patients with a wide variety of neurological disorders. It is essential that they develop the judgment and ability to assimilate significant and varying technical skills, in order to perform demanding operative procedures, many of which are done on an emergency basis, and can take as long as 16 hours to perform.

There are more than 6,000 U.S. hospitals, with approximately 3,300 actively practicing board-certified neurosurgeons serving a population of over 303 million people. There are already neurosurgeon shortages and serious access- to-care issues regionally across the United States, most notably in the areas of pediatric neurosurgery and emergency/trauma. Emergency care for head and spinal cord injury and for hemorrhagic stroke (both serious public health

concerns) falls disproportionately on this small number of neurosurgeons.

Potential implications of a maximum 16-hour shift and 56-hour resident work week for neurosurgery:

  • Current problems concerning access to neurosurgical care in trauma and emergency situations will likely be severely exacerbated by a reduction in resident work hours.
  • Residents will likely be unavailable to participate in operative cases at least one day out of five weekdays during which elective cases and the majority of emergency cases are performed.
  • It would be routine for patient care to be arbitrarily compartmentalized, resulting in more frequent "handoffs," which have been shown to increase the chance of clinical errors.
  • A reduction in clinical experience will result in physicians who are less skilled, performing surgeries requiring extremely high levels of skill.

"Given the numerous potential downsides of further limits on resident work hours, we must proceed with extreme caution and only after we have further research analyzing the affects of current rules," concluded Dr. Grady.

The authors report no conflict of interest.

Editors note: Dr. Grady, Chairman of the ABNS, will be fielding media interview requests. Please contact [email protected] or 847-378-0517 to arrange an interview.

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