Neurosurgery Resident Duty Hours and the Learning and Working Environment

bobGuest post from Robert E. Harbaugh, MD, FAANS, FACS, FAHA
Past President, American Association of Neurological Surgeons
Past President, Society of Neurological Surgeons
Director, Institute of the Neurosciences
Distinguished Professor and Chair, Department of Neurosurgery
Professor, Department of Engineering Science & Mechanics
The Pennsylvania State University
Milton S. Hershey Medical Center
Hershey, PA

After thirteen years of duty hours restrictions, it was important for the Accreditation Council for Graduate Medical Education (ACGME) to assess the impact those regulations had had on patient safety and resident training. So last year, on March 16-17, 2016, the ACGME convened a congress on resident duty hours in Chicago. It was evident to everyone who attended that the ACGME had made a real commitment to hear all the evidence and do what was best for our residents, our patients and our profession. I was impressed by the thoughtful analysis presented at that meeting by many medical and surgical disciplines. Almost universally, those physicians with the most experience in training resident physicians felt that the rigid shifts of the present system had had many negative consequences and asked the ACGME to ease work hour restrictions. Following the congress, the ACGME analyzed and discussed the voluminous data and made recommendations to improve the resident learning environment. These final recommendations, which were announced on March 10, 2017, include a modest increase in work hours for first-year residents and increased flexibility for all residents regarding their “shifts.”

acgme2Throughout this process, there was a commitment from the ACGME to collect and analyze the data rather than try to make the data fit a predetermined outcome. The response to the ACGME recommendations has, however, taken a different course. The proposal for modest changes in work hour restrictions has been met with invective from the usual suspects. Once again we hear the anecdotes of brutally mistreated residents putting their own and their patients’ lives at risk, the question of “Do you want an exhausted doctor taking care of you?” and the mostly meaningless comparisons to other jobs. What we haven’t seen is data to support the tantrums.

An ever-increasing volume of data, including data from prospective randomized trials, suggests that we accepted a false premise that restricting duty hours would improve patient safety and resident training. It is becoming increasingly clear that we have not enhanced the safety of today’s patients. As worrisome is the fact that we are also sacrificing the safety of future patients by adversely affecting resident training. Over the last decade, studies and surveys have documented the following negative consequences resulting from the current duty hour restrictions:

  • A reduction in the total hours of surgical experience;
  • The use of midlevel practitioners for educationally valuable activities;
  • Decreased time spent in outpatient clinics;
  • Fewer elective operations;
  • Compromises in the continuity of care; and
  • Reduced research and conference time.

Perhaps most important, current duty hour rules foster a shift-work mentality with its attendant loss of personal commitment to the patient. The current system forces our residents to choose between adherence to regulations requiring them to end their shift or their commitment to patients who would still benefit from their care. Neurosurgery is a demanding technical specialty, but we do much more than perform procedures. We care for our patients in the clinic, the emergency room, the operating room, the recovery room, the intensive care unit and the hospital wards. We are specialists in the care of patients with neurological disease, not merely technicians who have mastered a motor skill. We are professionals, not shift-workers. We have always taken care of our patients whenever they need us, for as long as they need us and we should continue to train our residents to put their patients’ interests first.

acgmeAdhering to an arbitrary shift schedule has erected significant barriers to neurosurgical training. Neurosurgical learning episodes — from initial contact with the patient, through diagnostic evaluation, surgical treatment and immediate postoperative care — encompass many hours. To obtain the greatest educational value from these learning episodes, a resident must be present throughout this sequence of events. When these episodes cross the shift boundaries set up by work hour restrictions, as is often the case, our residents are forced to decide between doing what is best for their patients and their education or following the rules that tell them that their shift is over and they must punch the clock.

Fatigue is a fact of life for neurosurgeons. Maximizing patient safety and resident education requires attention to supervision and fatigue management, not designated shifts. Supervision will vary according to the level of training, with junior residents requiring more immediate supervision than senior residents who are assuming a greater degree of autonomy and responsibility for patient care. The last years of resident training should be a transition to practice during which residents develop the time management, clinical and operative skills to become an independent neurosurgical practitioner. Allowing a more flexible schedule within the current 80-88 hour work-week and eliminating the work hour restrictions for 6th and 7th-year residents would help our trainees internalize the importance of continuity of care, take personal responsibility for their patients, avoid the moral dilemmas of the present system and enhance professionalism.

The modest changes adopted by the ACGME, which increase the work hours for first-year residents and give all residents a bit more flexibility regarding their “shifts” is a small, but critical step in the right direction.

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