A street intersection sticks in my memory from my neurosurgery residency years. I drove the two-mile distance from hospital to home every other evening, usually after dark, seeking a few hours of sleep, a change of clothes, and a chance to see my wife and young son, if he was still awake. I sometimes fell asleep, usually only nodding briefly, but sometimes sinking into profound stupor only to be startled awake by a blast from an automobile horn as I waited at the long stoplight only a quarter of a mile from home. Too fatigued to pause for even 60 seconds without fading out, I learned to set my foot tightly against the brake.
A room darkened for the Saturday morning neuropathology conference meant a catnap for a clouded mind after a Friday night on call. Even as little as two hours of sleep could stave off the torpor of sleeplessness.
Every neurosurgeon has a story, or many stories, of fatigue, countless long hours, and work to the point of exhaustion during training. For some the pace continues long after residency or fellowship, especially where emergency and trauma call is heavy. Subarachnoid hemorrhage respects no hours. Traumatic cerebral contusion knows no schedules. This is what our training taught us; this is what neurosurgeons do.
Whether training into and through a state of exhaustion was correct or even necessary is called into question by the limiting of resident work hours. The Accreditation Council for Graduate Medical Education (ACGME) has long endorsed a limit of 80 hours per week for resident work and call. The policy has not been vigorously enforced, until now.
The New York Committee on Interns and Residents (CIR), among others, was successful in lobbying for and gaining passage of a statute in New York State more than 10 years ago, limiting resident work to 80 hours per week. The law has not produced inferior neurosurgery residents. But it has made it harder to keep a clinical service covered.
Last year the CIR, citizens’ groups, and others lobbied unsuccessfully for a bill in Congress to similarly limit resident work hours nationwide. The AANS/CNS Washington Committee vigorously opposed any federal legislation mandating specific medical training work hours, believing it best to leave judgement in the hands of the professionals who designed and reviewed training programs, namely the ACGME and the residency review committees.
The arguments for limits on resident work hours are several. Fatigue clouds judgment, blocks learning, and leads to errors, which imperil patient safety. Even resident safety is threatened, when residents fall asleep on the road after two days of continuous call. Excess resident hours are often consumed by “scut work,” ancillary service without educational value and unrelated to actual physician responsibilities.
Arguments against the 80-hour week also exist and are compelling, at least to neurosurgeons. Neurosurgery is a specialty with an arduous training program; all other specialties know it and neurosurgery residents know it coming in. Limiting work hours reduces the number of patients for whom a resident can care, and can affect the continuity of care during cases, such as long surgical cases. Neurosurgery is a high risk, difficult discipline, requiring long hours of unflinching dedication to the patient, a lesson that must be learned by experience during training in preparation for the work hours demanded in practice, where a neurosurgeon can’t just walk off the job like a shift worker when an arbitrary time limit passes.
A further consideration for practicing neurosurgeons is a corollary to the restrictions on resident work hours. If 80 hours defines the limit of safe practice time per week for a resident, how can a practicing neurosurgeon safely commit more hours? Does this rule create a liability for any neurosurgeons who serve their communities more than 80 hours per week, creating simply another future problem of access to neurosurgery care? And regarding access to neurosurgery services, with neurosurgeons less available because of time restrictions, and emergency room coverage already a problem, won’t trauma and other neurosurgery emergency services become even scarcer?
Just to further complicate the issue, the European Union allows only 58 work hours per week for residents, to be dropped to 48 hours over the next decade. Denmark allows only 37 hours, yet does not lack neurosurgery service or adequately trained neurosurgeons. The issue of resident work hours is complex, but the ACGME restrictions exist and the enforcement penalty is high. For better or for worse, beginning this summer neurosurgery will experience another transition, this time to a limited resident workweek.
James R. Bean, MD, is editor of the Bulletin and chair of the AANS/CNS Washington Committee. He is in private practice in Lexington, Ky.