Time Tells – Residents Get Less Operative Experience After Workweek Restrictions

Will the newly minted neurosurgeon you hire be as well-trained as you were? For academicians and private practitioners alike, this is the million-dollar question. When the 80-hour workweek for all medical residents became effective July 1, 2003, the Summer 2003 issue of the AANS Bulletin offered an overview of the restrictions that were mandated by the Accreditation Council for Graduate Medical Education and explored their anticipated consequences. An opinion survey by Chang and Bell reported that the majority of respondents, 80 percent of neurosurgical residency program directors and 56 percent of residents, said they expected the restrictions to have a negative impact on neurosurgical training, among other findings. Some articles attempted to foresee the future of neurosurgical education, exploring workweek implementation methodologies and associated costs, while others reviewed the cost of New York’s 405 Regulations, which preceded the ACGME restrictions by a decade, and reported the progress of federal legislation that threatened to supersede the ACGME restrictions.

Now, with more than two years of data available, neurosurgery is beginning to apply evidence-based methodology to determine the actual impact of the restrictions on the medical education of its residents.

Authors of the two peer-reviewed studies in this issue analyzed data at their own neurosurgery training programs to determine the level of compliance with the work hour restrictions as well as the impact of the restrictions on the operative experience of residents. Both studies found compliance with ACGME restrictions. Both also found that the number of operative cases generally and significantly decreased for all residents. Interestingly, the distribution of the operative cases between junior and chief residents was inverted at the two institutions studied: At the University Okalahoma, chief residents performed significantly fewer cases compared with data predating July 2003, and junior residents, more cases. At the University of Utah, junior residents performed roughly half the cases they had prior to implementation of the restrictions while chief residents’ caseload remained largely unchanged.

Summary of ACGME Restrictions Complete information is available at www.acgme.org > Resident Duty Hours. 80 hours per week, averaged over four weeks, inclusive of all in-house call activities, with up to a 10 percent exception possible. One day in seven “off” (one continuous 24-hour period free from all clinical, educational, and administrative activities) averaged over four weeks, inclusive of call. 10 hours off between all daily duty periods and after in-house call. In-house call every third night, averaged over four weeks. 24 consecutive hours on-site, including call, with up to six additional hours for participating in educational activities and maintaining continuity of medical and surgical care. “Specialty Specific” Language for Neurological Surgery Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care. This may include resident participation in the first surgical case of the day. No new patients may be accepted after 24 hours of continuous duty. A new patient is defined as any patient for whom the neurological surgery service or department has not previously provided care. The resident should evaluate the patient before participating in surgery.

Even if the results of these two studies were extrapolated to all of neurosurgical education, would less operative experience necessarily mean that the neo-neurosurgeon you hire won’t be as well trained as you were? Common sense may suggest an affirmative response but, as authors suggest in this issue, the answer is far more complex.

To date, little additional data has been published regarding the impact of work hour restrictions on neurosurgical education. One study by Cohen-Gadol and colleagues surveyed neurosurgical program directors and residents in the three months immediately following implementation of the work hour restrictions. They found that 79 percent of the program directors and 61 percent of the residents said the ACGME guidelines have had a negative effect on their training programs, findings similar to those reported by Chang and Bell. The Cohen-Gadol study also reported that 93 percent of all respondents said the work hour restrictions have had a deleterious impact on patient care.

Of course, improving patient care as well as patient and physician safety was the primary aim of the ACGME in instituting the restrictions, and this also is the focus of related nationwide legislation. Whether the ACGME work hour restrictions are robust enough to stave off federal legislation remains to be seen. Federal legislation that restricts resident work hours and increases resident supervision has been introduced every year since 2001, most recently in the 109th Congress as the Patient and Physician Safety and Protection Act of 2005. In March H.R. 1228 was referred to the House Ways and Means Subcommittee on Health, and in June S. 1297 was sent to the Senate Committee on Finance. Text of each bill is available at https://thomas.loc.gov.

Data on the cost to neurosurgery programs of implementing the restrictions also is scarce in the published literature. The annual cost of hiring physician extenders to replace residents has been reported in the AANS Bulletin to be $350,000 and $400,000 at two different training programs. In this issue’s “Restrictions Get Reality Check,” the total annual cost of implementing work hour restrictions at one teaching hospital is estimated at nearly $1 million.

At least one study outside of neurosurgery attempted to analyze cost of the work hour reforms in relation to the benefit of preventing adverse events. In the October 2005 issue of the Journal of Internal Medicine, Nuckols and Escarce concluded that a decline in adverse events of 5.1 percent to 8.5 percent would make the reforms cost-neutral to society, but that a much larger drop of 18.5 percent to 30.9 percent would be needed to make them cost-neutral for teaching hospitals.

The impact of the resident work hour restrictions on neurosurgery is one of many areas ripe for further research. Those interested in pursuing such research are encouraged to review the writing guidelines for the AANS Bulletin, available at www.aans.org/bulletin.

Manda J. Seaver is staff editor of the AANS Bulletin.

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