| Abstract All residents in U.S. training programs are required to comply with work hour restrictions mandated by the Accreditation Council for Graduate Medical Education. The purpose of this retrospective study was to quantify the number of times this limit was exceeded since its implementation on July 1, 2003, as well as to gauge the impact of restricted work hours on operative case experience of residents. Data from the University of Oklahoma resident work hour database was analyzed and incidents of violation were characterized. Operative attendance was collected from departmental records. During the study period seven violations were recorded. Further investigation revealed that all supposed violations were attributable to errors in calculation or data entry and were not truly violations of ACGME-mandated rules. Residents were available to assist in more cases the year before the work hour restrictions took effect compared to the first year after they were in place. The differences were evaluated by the chi-square test and found to be significant (p < 0.0001). These results suggest that limited duty hours are feasible, albeit with a decrease in operative cases in which residents take part. The impact on patient care, continuity and training experience, however, must be studied further to determine if work hour restrictions are truly in the best interest of trainees and patients. |
Since July 1, 2003, all residents in U.S. training programs have been required to comply with restrictions on work hours mandated by the Accreditation Council for Graduate Medical Education. Residents may work no more than 80 hours per week averaged over a four-week period. In addition, specific restrictions apply to the number of continuous hours that “in-house” and “home call” residents may spend in the hospital. These restrictions were widely debated before their implementation, and the discussion continues today (5,9).
The purpose of this study was to quantify the number of times these limits were exceeded at the University of Oklahoma neurosurgery residency program since the inception of the 80-hour workweek. The study was also designed to characterize the most common reasons and situations for violations of the work hour rules. Additionally, the impact of the new work restrictions on residents’ ability to participate in surgical cases was examined.
| PEER-REVIEWED RESEARCH
Michael D. Martin, MD University of Oklahoma College of Medicine, Department of Neurological Surgery, Oklahoma City, Okla. Christopher E. Wolfla, MD Medical College of Wisconsin, Department of Neurological Surgery, Milwaukee, Wis. Correspondence to: M. Martin Received: Sept. 16, 2005 Accepted: Oct. 10, 2005 AANS Bulletin 14:14-16, 2005 Key Words: resident duty hours, neurosurgical residency, neurosurgical training Abbreviations: ACGME, Accreditation Council for Graduate Medical Education |
For this study, a retrospective analysis of data taken from the University of Oklahoma resident work hour database was performed. The university’s data system tracks the in-hospital hours of every resident on the campus. Hours are entered daily and averages are calculated every four weeks. When a resident is found to have exceeded 80 hours, the incident is forwarded to the program director and a written explanation must be made for the violation. The data system also tracks residents by their current rotation. Our study used this data to analyze and characterize the incidents in which a violation occurred.
For the second part of the study, departmental records were reviewed to assess the availability of neurosurgical residents to participate in operative cases. The department keeps these records, and their accuracy is checked in weekly meetings with all members of the resident and attending staff and then cross-checked with the online ACGME Resident Case Log System. For the purpose of this study, bedside procedures and stereotactic radiosurgery procedures were excluded. Residents are given credit for being present for part of the case, and in our internal reporting system only one resident may be credited for each case. There is no system in place for measuring the number of cases residents had to leave before completion due to work hour restrictions or other commitments.
Results During the period from July 1, 2003, to June 28, 2004, seven violations were reported by the University of Oklahoma resident duty hour database. In two instances, residents had entered the wrong information. Four instances were termed “frame of reference” violations. Examination revealed that these incidents did not violate ACGME or university rules, but were in fact related to which four-week period (or “frame”) the program chose to recognize. The other violation involved switching from at-home call to in-house call and confusion about the hour calculation in these different situations.
We calculated that junior residents averaged 71.2 hours per week while on the neurosurgery service, 52.1 hours per week during the research year, and 58.2 hours per week while on electives. Senior residents averaged 66.8 hours per week, excluding call taken from home.
From July 2002 through June 2003, 1,601 major operative procedures were performed in the neurosurgery department (Table 1). Residents were unable to assist with 146 of these cases, or 9.1 percent. Each resident performed an average of 242.5 cases. From July 2003 through June 2004, 1,517 major operative procedures were performed in the neurosurgery department. The department performed fewer operations during the second year of the study (2003-2004) in part due to the departure of one attending neurosurgeon near the end of the study period. Residents were unable to be present for 240 cases, or 15.8 percent. Each resident covered an average of 212.8 cases. The difference was evaluated by chi-square test and found to be significant (p < 0.0001).
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Discussion Resident work hour restrictions have forced training programs to monitor the hours of their trainees. Prior investigations have yielded mixed reviews of the restrictions and their impact on surgical training. Studies have shown that program directors, practicing surgeons and senior residents do not generally believe that training has improved as a result of the limited work hours (4,10,12-14). Evidence suggests that, on the whole, current surgical trainees believe that work hour reductions have improved their quality of life (3). In one study of otolaryngology program directors, 45 percent of respondents felt that the restrictions had resulted in increased faculty workload (8). Still another study showed that signs of “burnout” were unaffected by the decreased work hours (6). Some programs have reported difficulty in maintaining the new work hour limits due to factors such as level 1 trauma status (4) and activities deemed to be “noneducational” (2).
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Our study is limited in that the data obtained is from only one institution and only covers a two-year period. The aforementioned lack of surveillance of residents who must leave cases early is another potential piece of information that would make the data more robust. We also have made no attempt to determine whether the personal preferences of the chief residents for certain cases over others may have falsely elevated or decreased their numbers. Also, although every measure was taken to ensure accurate recording, no guarantee can be made that the systems used for recording data are without flaws.
Conclusions This study examined the feasibility of working within the ACGME-mandated guidelines and the effect that the presumably reduced time at work had on resident surgical exposure. The results clearly show that even in a one-resident-per-year program covering four hospitals, compliance can be achieved. This compliance, however, was not achieved without significant changes to the resident operative experience. The percentage of cases not covered by residents increased, and further examination revealed that the operative experience of the chief residents dropped significantly. These numbers are conservative estimates. No account can be made for residents who may have had to leave the case before completion or before the critical portion of the operation was accomplished. At this time the long-term effects of decreased operative exposure are not known.
Clearly more research must be done, especially regarding the impact that the work hour restrictions will have on those currently in neurosurgical training. The restricted hours simply have not been in place long enough for their impact on lengthy training programs such as neurosurgery’s to be fully realized. While it is apparent that many in our field do not agree with these rules, it is imperative that further study be carried out to ensure that trainees graduating from neurosurgical residency are equipped to operate in this most challenging specialty.
