Robert E. Harbaugh, MD, FAANS, FACS, FAHA
President, Society of Neurological Surgeons
On March 16-17, 2016, the Accreditation Council for Graduate Medical Education (ACGME) convened the“Resident Duty Hours in the Learning and Working Environment Congress“ in Chicago. Before the meeting, leaders of organized neurosurgery submitted a white paper on resident duty hours to the ACGME, and I gave testimony at the Congress based on that document. Neurosurgery was well represented at the Congress. H. Hunt Batjer, MD, FAANS (AANS president), Russell R. Lonser, MD, FAANS (CNS president), Shelly D. Timmons, MD, PhD, FAANS (AANS/CNS Washington Committee chair) and I were there for the duration of the meeting. Additionally, neurosurgical resident Maya Babu, MD, PhD, presented testimony on behalf of the American College of Surgeons. Our statement was well received, and there was a near consensus among the testifying organizations that the rigid shifts of the present system had had many unanticipated and negative consequences for resident training. I believe that it was clear to everyone attending the Congress that the ACGME has made a real commitment to hear all the evidence and do what is best for our residents, our patients and our profession.
In 2003, the first national restrictions on duty hours worked by neurosurgery residents were instituted by the ACGME. It is important to assess the impact of those regulations on patient safety and resident training because the quality of care we deliver to our patients today and in the future and the values we instill in our residents hang in the balance.
What we have learned about the current restrictions has been very disappointing and a cause for great concern among those of us most interested in the quality of neurosurgical training. In the last 13 years, studies and surveys have documented deleterious effects from duty hour restrictions. These include a reduction in the total hours of surgical experience, the use of midlevel practitioners for educationally valuable activities, decreased time spent in outpatient clinics and elective operations where medical judgment and surgical techniques are refined, compromises in the continuity of care for neurologically unstable patients 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.
An ever-increasing volume of data, including data from prospective randomized trials, suggests that we have accepted the false premise that restricting duty hours will improve patient safety. It is becoming increasingly clear that we have not enhanced the safety of today’s patients, but we are sacrificing the safety of future patients by adversely affecting resident training and we are imposing a shift-work mentality on those who should be learning to be consummate professionals. The present system forces our residents to choose between adherence to regulations requiring them to end their shift or the higher calling of their commitment to patients who might still benefit from their care. If they choose the latter, they must lie or put their program at risk. A system that makes our residents feel they must lie about doing the right thing is a system in need of improvement.
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 technicians who have mastered a motor skill. We have always taken care of our patients whenever they need us, for as long as they need us. This is a founding principle of our specialty that we must not abandon. We vigorously support training our residents to become neurosurgeons, not technicians.
Mastery of the knowledge and skills required to manage the long list of neurosurgical disorders requires many years of commitment and intensive experience. Neurosurgical learning episodes — from initial contact with the patients, through their evaluation, surgical treatment and immediate postoperative care — encompass many hours. To obtain the greatest educational value from these learning episodes, and to offer the safest care for neurosurgical patients, 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 because their shift is over, they must punch the clock. We need to take our residents off the horns of this dilemma.
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 will help our residents internalize the importance of the continuity of care, take personal responsibility for their patients, avoid the moral dilemmas of the present system and enhance professionalism.
Our specific recommendations for neurosurgical training are as follows:
- PGY 1 (post-graduate year one — the first year of residency after graduating from medical school): 80 hours per week, averaged over four weeks, one day in seven off-duty, averaged over four weeks and 10 hours off between duty shifts. In-house call — a 24-hour shift — may be followed by up to 10 hours to permit the resident to participate in the operating room, participate in didactic activities and maintain continuity of care. These changes would reclaim the PGY1 year as the first year of resident training rather than its present role as the fifth year of medical school.
- PGY 2 to 4: 88 hours per week, averaged over four weeks, one day in seven off-duty, averaged over four weeks, 10 hours off between duty shifts. In-house call may be followed by up to 10 hours to permit the resident to participate in the operating room and didactic activities and maintain continuity of care and residents may stay on duty or return to the hospital with fewer than 10 hours free of duty to provide continuity of care for severely ill, complex or unstable patients, for events of exceptional educational value or for humanistic attention to the needs of a patient or family.
- PGY 5: 88 hours per week, averaged over four weeks and one day in seven off-duty, averaged over four weeks.
- PGY 6 to 7: One day in seven off-duty, averaged over four weeks. These last two years of training serve as a transition to practice.
We believe that these recommendations would improve patient safety and benefit resident training. They would remove the shift-work aspects of the present system and allow a graduated transition to neurosurgical practice. We are grateful to the ACGME for allowing us to share our views on duty hours and the resident training environment.
Editor’s Note: During the month of March, we encourage everyone to join the conversation online by using the hashtag #gmemonth.