Duty Hour Restrictions: What Have We Learned? Where Do We Go From Here?
This week, an important study regarding duty-hour restrictions was published in the New England Journal of Medicine (1). This study is the report on the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial.
The report, written by Karl Bilimoria, MD, MS, and colleagues, represents a national cluster-randomized trial of duty hour flexibility. The trial involved 117 general surgery residency programs in the U.S. for the 2014-2015 academic year. The programs were randomly assigned to the current Accreditation Council for Graduate Medical Education (ACGME) Duty Hour Policies or to more flexible policies that waived certain rules on maximum shift lengths and time off between shifts. Outcomes analyzed include the 30-day rate of post-operative death or serious complications, other post-operative complications and resident perceptions regarding their well-being, education and patient care.
In the final analysis, flexible and less restrictive duty-hour policies were not associated with an increased rate of death, serious complications or with any change in resident satisfaction with their overall well-being and education quality. What does this mean?
Let’s go back. In October, 1984, an 18-year-old woman named Libby Zion was admitted to The New York Hospital. She had been taking Nardil, an MAO inhibitor, and became more agitated after admission. She was administered Demerol and developed severe hyperthermia and ultimately, cardiac arrest. Her death, while tragic, had nothing to do with physician fatigue.
This was a very rare drug interaction that was little known at that time. Legal actions by her father following her death focused on overwork and lack of supervision for the young physicians involved. Ultimately, this case catalyzed action by the state of New York imposing duty hour restrictions of 80 hours per week, with no longer than 24 hours of continuous work on shift.
Subsequent actions by the Institute of Medicine (IOM) and, ultimately in 2003 by the ACGME, led to the imposition of duty-hour restrictions across all of ACGME accredited training programs, a truly transformative event. These standards were revised in 2011, and periodic calls continue to surface demanding further reductions in weekly duty hours to the range of 56 hours per week. Organized neurosurgery has supported the ACGME standards and fought further duty restrictions aggressively.
What Do We Currently Know?
On the occasion of the tenth anniversary of the 2003 duty-hour restrictions, Drs. Anil Nanda, MD, MPH, FAANS; Fredric B. Meyer, MD, FAANS; and I utilized all available published information, outcomes from citations through the ACGME Residency Review Committee and performance by trainees and graduates on various components of the American Board of Neurological Surgery (ABNS) certification process.
Our findings were reported back to the Society of Neurological Surgeons (SNS) and included the following:
- Isolating outcomes to duty hours alone is very difficult;
- Training in neurosurgery occurs in a highly complex milieu of environmental factors — duty hours are but one, and probably a minor variable;
- Our training programs have evolved substantially in the decade since post-duty-hours restrictions, making an “on-off” comparison with 2003 difficult;
- It is possible to train neurosurgery residents well within the 80/88 hour restrictions. However, there has been evidence of a decay of professional commitment by our trainees; and
- Further reductions are a “no-go.”
A recent editorial written by Ralph G. Dacey, Jr., MD, FAANS, has thoughtfully reassessed what we currently know (2). He cited the difficulties with the interpretation of the ACGME survey instruments in which residents may make an incorrect choice based on vague wording, and thus, put a program into non-compliance with punitive results.
He further cited the dilemma of programs and residents struggling to comply with complex regulations that put them into direct conflict with their professional responsibilities for our patients. Do they violate the Duty Hour Standards, honor their professional responsibilities and then falsify their duty hours reporting? Putting our young physicians into this dilemma is unacceptable. It should be noted that there is a tremendous difference between a post-call physician going into a dark room to read EKGs or x-ray images compared to a neurosurgeon, post-call, walking into a bright, bustling and vibrant emergency department.
Much of the sleep physiology leading to the IOM recommendations occurred in the former type of environment. Ganju recently reported that neurosurgery residents (post-call) demonstrated significantly less fatiguability in complex psychometric and technical exercises than did general surgeons post-call (3). This finding suggests that the genotype and phenotype of those young physicians who pursue neurosurgery are different than those pursuing other fields. As a result of current policies, prolonged duty hours have been replaced by multiple hand-offs of care, loss of continuity of care and decay of the professionalism of our young physicians. We are now 13 years into the 80/88 hours-standard, and we have no evidence whatsoever of a positive impact on patient outcome.
Return the Focus to the Patient’s Best Interest
Going forward, it is critical that neurosurgery fight new cries for stricter duty-hours standards and hold the line — 56 hours is the wrong answer for neurosurgery. I believe that we will be successful through upcoming ACGME deliberations in recovering the PGY-1 year to an actual year of professional training, rather than a fifth year of medical school.
I believe we will also be successful in recovering the chief-residency year to become a transition into independent practice and not deprive residents at this critical moment of access to high value educational experiences, complex operative challenges and coming to grips with the meaning of professionalism in our discipline.
As professionals, we should be allowed to recognize that fatigue is an inescapable element of training and practicing in neurological surgery. We need to be empowered to manage this fatigue by recruiting help when we need it, taking naps and other simple means. We need to return the focus to the patient’s best interest and allow professionalism — not regulation — to manage fatigue in surgical practice.
1. Bilimoria KY, Chung JW, Hedges LV, Dahlke AR, Love R, Cohen ME, et al: National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training. N Engl J Med, 2016
3. Ganju A, Kahol K, Lee P, Simonian N, Quinn SJ, Ferrara JJ, et al: The effect of call on neurosurgery residents’ skills: implications for policy regarding resident call periods. J Neurosurg 116:478-482, 2012
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