In anticipation of the July 1 effective date of the Accreditation Council for Graduate Medical Education (ACGME) restrictions on resident work hours, last spring neurosurgery appealed to the ACGME for an “exemption from specific limited aspects” of the duty hours standards that the ACGME proposed in June 2002. The application for exemption, drafted by Ralph G. Dacey Jr., MD, chair of the Department of Surgery at Washington University School of Medicine in St. Louis, detailed the characteristics of neurosurgical training as well as probable effects of resident work hour restrictions on neurosurgical training programs.
According to Dr. Dacey, at its February 2003 meeting the ACGME tabled neurosurgery’s request. “The ACGME has said that it will consider requests for specialty-wide exceptions after its new requirements have been in place for one year,” he stated. “The Committee on Program Requirements of the ACGME considered the proposal at its meeting in June and denied the request for specialty-wide exemption. It is conceivable that another specialty-wide exemption for neurosurgery could be considered by the ACGME next year.”
The application for exemption stated in part:
While recognizing the importance of appropriate limits on [resident duty hours], many neurosurgical educators have serious concerns about the impact of these proposed common standards on the process of educating a neurosurgeon. Clearly resident fatigue has the potential to cause adverse patient outcomes, but if the neurosurgical educational process is severely compromised it is very likely that more adverse outcomes will result from inadequately trained residents …
We support the efforts of the ACGME to improve resident education and as a group we are actively preparing for the new requirements. We feel that the [proposed residency duty hours standards] will improve resident education overall but some aspects of the standards may make it difficult to effectively prepare neurosurgical residents for ultimate independent practice.
Is Neurosurgery “Different”?
“Neurosurgeons are not different from other physicians, but the diseases they care for and the context in which they work and learn are quite different.” The complexity of the nervous system itself, the breadth and depth of neurosurgical cases, and the rapidity of onset and severity of consequence of neurosurgical complications were among the factors cited in support of exemptions from work hour restrictions.
Other evidence pointed to the relatively few practicing neurosurgeons in the United States who must provide neurosurgical care to an aging population; in 2001 there were fewer than 3,000 to staff more than 6,000 U.S. hospitals. Out of 16,000 medical students, neurosurgical training programs select only 143 first year residents, and after the first year, most programs train one resident per year for five or six years, amounting to slightly more than 800 neurosurgeons in training.
Neurosurgical training includes one year as chief resident, a transitional year to independent practice described as “the most important part of the [training] experience” because “it is only through this type of multitasking experience that a chief resident learns his or her limits and develops the emotional stamina to care for sick neurosurgical patients.” These factors and others led to the development of the four exemptions requested of the ACGME:
Proposed Regulation:
Residents must not be scheduled for more than 80 hours per week, averaged over a four-week period, with the provision that individual programs may apply to their sponsoring institution’s Graduate Medical Education Committee (GMEC) for an increase in this limit of up to 10 percent if they can provide a sound educational rationale.
Exemption Requested: Neurosurgical educators request that neurosurgery resident duty hours be limited to a maximum of88 hours per week averaged over a four-week period.
Proposed Regulation:
Continuous time on duty (call) is limited to 24 hours, with additional time up to six hours for inpatient and outpatient continuity, transfer of care, educational debriefing and formal didactic activities. Residents may not assume responsibility for new patients after 24 hours.
Exemption Requested:
Because of the potential adverse effect of the 24-hour limit on resident operative experience and continuity of care, we request that residents be permitted to participate in first surgical cases scheduled for the “post call” day.
ACGME Proposed Regulation:
Residents should have a minimum rest period of 10 hours between duty periods.
Exemption Requested: In programs operating “night float” arrangements, we request eight hours between duty periods be permitted.
Proposed Regulation:
When residents take call from home and are called into the hospital, the time spent in the hospital must be counted toward the weekly duty hour limit.
Exemption Requested: Because of the special importance of the chief resident experience, we request that chief residents be exempted from [resident duty hours] restrictions. Exemptions were not requested for the following regulations:
- Residents must have at least one full (24-hour) day out of seven free of patient care duties, averaged over four weeks.
- Residents must not be assigned in-house call more often than every third night, averaged over four weeks.
Manda J. Seaver is staff editor of the Bulletin.