While medical training programs nationwide adjust to comply with the July 1 effective date of the restrictions on resident work hours mandated by the Accreditation Council for Graduate Medical Education (ACGME), and the U.S. Congress considers a bill that would make similar restrictions the law across the United States, the attention of many is drawn to New York, where restrictions on resident work hours have been in place for more than 10 years.
In 1989, Section 405 of the New York State Health Code became the guiding regulation governing resident work hours in New York. This unusual step by a state government resulted from the 1984 death of a patient at a teaching hospital in New York City. Substantial publicity of the case resulted in the State Health Commissioner’s appointment of an advisory committee under the leadership of Bertrand Bell, MD, to review the management of the case. The Bell Commission noted that resident fatigue and lack of attending supervision were possible factors that lead to the patient’s demise. Hence, the commission recommended stricter supervision of residents, as well as restrictions on resident work hours, and the New York legislature passed what has become known as the 405 Regulations.
In 2000, fueled by the death of a cardiology fellow in a vehicular accident after being on night call, the state legislature passed the Health Care Reform Act. Included in the newer law were funds for hospital audits and stiff penalties for hospitals not in compliance with the 405 Regulations. Island Peer Review Organization, or IPRO, subsequently won the contract for audit services.
The current New York regulations require that residents work no more than 80 hours per week averaged over a four-week period and no more than 24 hours per shift, with 24 consecutive hours off per week. There are exceptions for surgical residents such that they can be exempted from the 80-hour limit if the hospital schedules them for call no more than every third night, can document that residents are generally resting when on call (difficult criteria to fulfill for most institutions), has procedures in place to relieve a fatigued on-call resident when necessary, and ensures 16 hours off following each day of call.
As a recent neurosurgical resident and current attending physician, and as chair of a surgical department, we hope to shed some light on how others might comply with the ACGME’s restrictions. Our own experiences with the implementation of New York’s 405 Regulations at Albany Medical Center, an academic health center that includes Albany Medical College and Albany Medical Center Hospital, provide a measure of insight into the transitional period in which many healthcare personnel across the nation now find themselves.
A Resident/Attending’s Perspective: Alan S. Boulos, MD
From the perspective of first a resident, and now as an attending physician, I have had the opportunity to view the process of compliance with New York’s 405 Regulations. While the 405 Regulations have been in existence since July 1, 1989, it was during my senior years in residency that the regulations first were strictly enforced. The two main difficulties that were immediately encountered were that the clinical responsibility for patients had to shift in order to allow residents time off on the day after on-call service, and operative cases in some instances had no resident coverage. Both of these changes impacted the education of the residents by reducing their exposure to clinical experiences.
Now as an attending, I have a first-hand understanding of the importance of attaining a greater breadth of neurosurgical experience during residency. Furthermore, the intensive first year of neurosurgical training with emphasis on nonoperative patient care responsibilities is intended to result in efficiency and facility to make critical clinical decisions, even when one is fatigued; this facility may develop unevenly by dilution of the residency experience and limitations on work hours.
New York’s 405 Regulations have resulted in a number of substantial changes in the day-to-day functioning of neurosurgical residency programs. Several changes in the residency program at Albany Medical Center have had mixed results. The most profound change has been the use of “at home” call. By allowing the resident to take call from home, the work hour clock is reset so that the resident may work the following day. This has improved the quality of life for the resident, but it has also made call more challenging by changing the question of, Do I need to get out of bed to see this patient, to Do I need to drive to the hospital to see this patient. The time commitment changes with each of these scenarios: only 10 minutes may be required for the former, while the latter requires the addition of travel time to and from the hospital, perhaps 20 minutes to one hour. In practice, when taking call from home and the necessity of checking on a patient is not clearly indicated, the addition of travel time can function as a disincentive to see a patient.
The scope and technical components of neurosurgery are evolving rapidly at a time when the educational paradigm has been changed abruptly by limitations on resident work hours. The residents are not immersed in the field to the same degree, and therefore they do not gain the same clinical experience. The change has resulted in an increasing number of residents continuing their education through fellowships.
The work hour limitations do not apply to fellows or attending staff. The ability to work in strenuous circumstances, including fatigue, is part of an attending’s everyday experience; therefore, the 405 Regulations do harm by preventing residents from learning and taking care of patients under those conditions.
Overall, the changes in resident education that are the product of the work hour restrictions may result in an increasing number of graduating residents being ill prepared for what is to come.
A Department Chair’s Perspective: A. John Popp, MD
At Albany Medical Center, the responsibility falls on the department chair to assure the institution’s Graduate Medical Education Committee that the seven surgical resident training programs are in compliance with 405 Regulations as they apply to supervision of residents and restrictions on work hours. When these regulations initially were promulgated, each department was asked to describe how it would bring programs into compliance and ensure that no aspect of the 405 Regulations would be violated.
The Department of Surgery’s plan to cover the supervisory aspect of the 405 Regulations was to identify one general surgeon, certified by the American Board of Surgery, who would serve “in-house” on nights and weekends. Having such an individual readily available for all surgical services, as well as to adjudicate and triage all cases that required supervision, would ensure appropriate patient care until the patient’s actual attending physician was contacted.
Similarly, a portion of the department’s plan to comply with the restrictions on resident work hours centered on identifying alternative providers of care who could fill the personnel void created by strict adherence to the 405 Regulations. Several physician assistants and nurse practitioners, collectively termed physician extenders (PEs), were identified.
Surprisingly, unlike most government mandates concerning healthcare services, the regulations provided for at least partial financial support of the necessary steps for compliance. The Department of Surgery annually has received approximately one-half of the sum that it determined was necessary for compliance. The department currently employs several PEs and a general surgeon who receives a stipend for in-house availability each night and every weekend for resident supervisory responsibilities.
Adjusting schedules to comply with the resident work hour component of the 405 regulations has been more challenging. Some divisions of surgery with a sufficient number of residents have instituted a night-float rotation such that residents on the rotation begin call in-house at 6 p.m. and leave in the morning after sign-out.
Some surgical specialties allow residents to take call from home. In this setting, the clock is not running continuously as it is in the case of in-house call. That is, if the resident gets a reasonable amount of sleep while taking call from home, then the period of at-home call does not count toward either toward the 80-hour workweek or toward the 24-hours of continuous call limitation, and compliance with the 405 Regulations can be achieved more easily.
Of all the surgical specialties at Albany Medical Center, the neurosurgical residency program has experienced a particularly challenging time meeting the criteria established by the 405 Regulations. The AMC’s neurosurgical residency program trains five residents. Each spends one year at the adjacent Veteran’s Administration hospital, one year in the research laboratory, three months on the required neurology rotation, and three months on neuroradiology and neuropathology. Each resident also receives four weeks of vacation and/or meeting attendance time, which from the perspective of the neurosurgical training program adds up to five months with one less neurosurgical resident available for call.
To bring the neurosurgical training program into compliance, a number of changes were introduced: 1) The three-month neurology rotation has been moved into the first year of training; 2) all residents, including the lab resident, take night call; 3) residents on the neuroradiology and neuropathology rotation or assigned to the laboratory, on an ad hoc basis may be called upon to assume daytime clinical responsibilities; and 4) a growing number of surgical cases do not have resident involvement.
None of these changes to our training program has enhanced residency training, and some may have diminished the breadth of resident experience. Some rhetorical questions to ponder:
- Are one-resident-per-year programs anachronisms since the latitude to meet the educational priorities is missing?
- Should residency training in neurosurgery be lengthened to ensure that residents have the appropriate amount and breadth of clinical experience?
- Should residency education in neurosurgery be entirely revamped? After all, the specialty of neurosurgery has changed dramatically in the past 30 years, and yet we are educating residents in the same paradigm that was in place decades ago.
Alan S. Boulos, MD, is assistant professor and Herman and Sunny Stall Chair in Endovascular Neurosurgery at Albany Medical College in New York.
A. John Popp, MD, is the 2003-2004 AANS president. He is Henry and Sally Schaffer Chair of Surgery at Albany Medical College.