Guest Post from
Maya A. Babu, MD (left)
Neurosurgical Resident, Mayo Clinic
Rochester, MN
and
Brian V. Nahed, MD (right)
Assistant Professor of Neurosurgery
Massachusetts General Hospital and Harvard Medical School
Boston, MA
The recent Institute of Medicine (IOM) report heralding potentially major changes in the world of graduate medical education (GME) funding has brought the whole issue of residency training and its finances into the spotlight. One critical aspect of resident training – which resulted, in part, from an earlier IOM report – that is often overlooked is the unintended consequences on physician training resulting from work hour restrictions. Intended to protect residents and patients from fatigue-related medical errors and accidents, there is a growing recognition that these regulations are failing to serve their intended goals.
Duty hour restrictions and polices on fatigue have led to major changes in residency training programs across specialties. Recommendations by the IOM1 and groups such as Public Citizen3 have called for more oversight and restricted work hours to promote patient safety. In response, training sites have expanded the workforce, often with nurse practitioners and physician assistants who, alongside, residents, distribute the increasing demands of clinical paperwork and procedures both in the operating room and at the bedside.
Critics of duty hour restrictions posit that trainees have less clinical exposure during residency and this experience may be skewed (for example, more time in surgery and less in pre- and post-operative care). As a result, fellowships are on the rise in order to gain exposure to varied and specialized patient cases.5 Fellowships traditionally were reserved for sub-specialties but have now evolved to complete the basic training previously considered part of the residency. For instance, the American College of Surgeons has pioneered the “Transition to Practice” fellowship, meant to be a year of fellowship in which trainees engage in autonomous operative and clinical decision-making. This provides many of the experiences previously considered an essential part of the chief resident year. Duty hour restrictions, coupled with requirements for attending physicians to participate in the 
critical portions of operative cases, significantly limit the independent performance of surgery and decision making by chief residents, necessitating this additional year.6
Potentially compounding the problem is the looming threat of cuts in Medicare GME funding for residency training programs. In 2008, the median GME cost per full-time equivalent (FTE) resident across teaching hospitals was $134,803.7 In neurosurgery, the institutional and departmental costs associated with training neurosurgical residents total approximately $1.2 million per resident over the course of a seven-year residency.8 Given these high costs, in the wake of potential funding cuts, hospitals may consider limiting or replacing residency positions with midlevel practitioners.
In the context of duty hour regulations and the necessary expansion of the clinical workforce to meet our nation’s healthcare needs, budgetary cuts in graduate medical education may undermine residency training as a whole. As training lengthens and physicians become super sub-specialized, careful thought should be given to the future of residency education, especially in the field of neurosurgery.
References
1. Nasca TJ, Day SH, Amis ES, Jr. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med 2010;363:e3.
2. STS Urges Debt Negotiations to Include SGR Reform, GME Funding. 2011. (Accessed at http://www.sts.org/news/sts-urges-debt-negotiations-include-sgr-reform-gme-funding)
3. Blum AB, Raiszadeh F, Shea S, et al. US public opinion regarding proposed limits on resident physician work hours. BMC Med 2010;8:33.
4. Bath J LP. Why we need open simulation to train surgeons in an era of work-hour restrictions. Vascular 2011.
5. Niederee MJ, Knudtson JL, Byrnes MC, Helmer SD, Smith RS. A survey of residents and faculty regarding work hour limitations in surgical training programs. Arch Surg 2003;138:663-9; discussion 9-71.
6. Jeyarajah R, Swanstrom LL, Aye RW, Wexner SD Martinez JM Ross SB, Awad MM, Franklin ME, Arregui ME, Schirmer BD, Minter RM. General Surgery Residency Inadequately Prepares Trainees for Fellowship Results of a Survey of Fellowship Program Directors. Annals of Surgery. 2013;258(3):440-449.
7. Wynn, B. O., R. Smalley, and K. Cordasco. 2013. Does it cost more to train residents or to replace them?A look at the costs and benefits of operating graduate medical education programs. Santa Monica, CA: RAND Corporation. (Accessed at http://www.rand.org/pubs/research_reports/RR324)
8. Ensuring an Adequate Neurosurgical Workforce for the 21st Century 2012. (Accessed at http://www.aans.org/pdf/Legislative/Neurosurgery%20IOM%20GME%20Paper%2012%2019%2012.pdf)
