“They’re going to restrict resident hours…”;
“Congress will pass a law…”;
“Can you believe 80 hours a week…?”
First there were rumors, then threats, and finally the bone-chilling reality: On July 1, 2003, the Accreditation Council for Graduate Medical Education implemented work hour restrictions for all medical residents. Not surprisingly, neurosurgery has survived the intervening two years, and a look at how the specialty has complied with the ACGME’s changes, how residents and attendings have coped, and how neurosurgery might rethink the resident training paradigm now seems to be in order. To this end, I offer my views based on my experiences with the residency program at the University of Maryland as well as observations from visiting different programs around the country.
Programs Adjust to Work Hour Restrictions; Resident Fatigue Is Relieved
The 80-hour workweek can be traced to a New York case in which resident fatigue was deemed to have contributed to a patient’s death. In 1989 the New York legislature passed resident work hour restrictions, commonly known as the 405 Regulations, although they were not fully enforced until recently. Similar regulations were voluntarily mandated by the ACGME, the governing body of all residencies and sponsor of neurosurgery’s residency review committee, essentially under the threat of national legislation or workplace rules instituted by the Occupational Safety and Health Administration. Adding fuel to this movement were tragedies involving post-call residents in motor vehicle accidents.
Numerous accounts indicate that compliance with the guidelines has been excellent. While the 80-hour workweek does represent an unfunded mandate, most programs have responded appropriately by increasing the use of physician extenders and home call, funding an increase in length of residency, and assigning extra residents to take call; I am not aware of any programs in which attendings have taken over in-house call. In programs with several residents, the night-float rotation (a dedicated resident taking night call only) has been popular. While the educational merits of this practice may be debated, in my opinion, it isn’t a bad way for the more junior residents to learn management of patients in the intensive care unit.
Anecdotal evidence suggests that in some programs residents are covering fewer cases, but my overall impression is that the resident operative experience has been unchanged — a point confirmed by an article in the May 2005 Journal of the American College of Surgeons. This article does point out, however, that there has been a drop in coverage of outpatient clinics.
While the fears of compromised resident education may have been alleviated, questions remain about a change in the prevailing attitude within training programs. An inevitable “shift mentality” takes over when one is required to turn over work and responsibility to another person. Some lapses are inevitable, but there seems to be more tolerance of less-than-perfect patient care at all levels (including the attending level), perhaps in recognition of the Sisyphean nature of modern American medicine. It will be a worthy challenge for neurosurgery to maintain or even to improve its standards of quality.
The greatest benefit of the 80-hour workweek is that resident fatigue has largely been relieved, and, if one follows the logic underlying the work hour restrictions, that patients therefore are safer. It also isn’t “Pollyannaish” to say that residents deserve to have humane working conditions, and attendings need to get over the fact that we worked 120 hours a week (in the snow, uphill, both ways).
If Fine-Tuned, Restrictions May Offer Opportunities
In fact, under the right circumstances, residents could be encouraged to use their “extra time” to increase their academic productivity. The right circumstances might involve an addendum to the current policy which, if residents could pass certain fatigue tests, would relax the restriction of 30 consecutive hours worked with 10 hours off between shifts (that word again) and allow them to finish clinic, or go to conference or to the lab if they choose.
Although most programs have coped well with the 80-hour workweek, the restrictions have strained some programs; those programs with one resident per year have arguably experienced the greatest difficulty. Further, the ability for neurosurgical residents to cover multiple types of hospitals — for instance a Veteran’s Administration or children’s hospital — and thus be exposed to a variety of educational experiences, has been compromised.
As we develop solutions for the work hour restrictions, we must avoid exacerbating the apparent current shortage of neurosurgeons. It is time to reevaluate our training practices. More neurosurgeons need to be trained — perhaps by adding new programs and more residents to existing programs, or shortening the length of some programs. But I’ll leave that meaty topic for a future Residents’ Forum.
Lawrence S. Chin, MD, is professor of neurosurgery at the University of Maryland Medical Center in Baltimore.