Restricted – The Impact of Residents 80-Hour Workweek on Neurosurgical Resident Training and Patient Care

In many ways, the 80-hour workweek guidelines set forth by the Accreditation Council for Graduate Medical Education (ACGME), effective July 1, 2003, seem to be a leap forward into a civilized era of medical training characterized by enlightenment and foresight. Neurosurgeons will be among the agents of implementation of these guidelines, as well as recipients of the consequences that follow.

In order to evaluate the guidelines’ perceived impact on training and patient care in neurosurgery, a confidential questionnaire was sent by e-mail to every neurosurgical resident and program director in the United States. Preliminary results of this survey were presented in the spring at the AANS Annual Meeting, and final results are released in this article.

The data are based on a 42 percent response from neurosurgery residency program directors and an approximately 10 percent response from neurosurgery residents. An overwhelming majority of program directors (79 percent) and more than a majority (62 percent) of the residents opposed the work hour restrictions. Fifty-nine percent of program directors and 40 percent of residents believed that the guidelines would affect patient care negatively. Eighty percent of program directors and 56 percent of residents felt that the guidelines would have a negative impact on training. Sixty-six percent of program directors felt that training duration should not be lengthened despite the shortfall in educational opportunities imposed by the guidelines, while 86 percent of trainees were opposed to extending the length of neurosurgery residency.

The respondents suggested several solutions to the problems that are anticipated as a result of ACGME work hour restrictions. These included lengthening-or shortening-the residency program, petitioning for more resident positions, hiring pre-residency fellows, instituting a night-float system, reducing elective/research time, reducing resident involvement in cases, having academic attending physicians take primary night call, creating more post-residency subspecialty fellowships, and employing nurse practitioners and physician assistants, collectively known as physician extenders (PEs), to cover those non-educational duties traditionally performed by neurosurgery residents.

Respondents’ comments were vehement and passionate. Many felt that the loss of auto-regulation and self-determination would erode the professionalism important in neurosurgery. Loss of continuity of care was a point of concern for most individuals at all levels of seniority. Virtually all trainees and program directors predicted a reduction in educational and operative opportunities. In particular, trainees’ exposure to the subspecialties involving intracranial pathology, such as cerebrovascular, tumors, trauma, and skull base, was felt to be affected most negatively by the new guidelines. Concern over the transition to a “shift worker” mentality was a prevalent theme. Many thought that the finishing residents would not be prepared for the “real world” responsibility of functioning as an attending neurosurgeon. It was generally felt that the guidelines would have an extremely detrimental impact on academic neurosurgery, adding to an already compromised academic neurosurgical structure in the United States.

Firm conclusions cannot be drawn from the data because a 100 percent response from program directors and residents could not be obtained. However, each of the prevalent themes deserves further scrutiny. The following paragraphs reflect opinions of the authors and do not represent the official views of any other individuals or organizations.

Lengthening Residency. Lengthening residency appears simple enough, but perhaps monumentally difficult to implement because of neurosurgical workforce considerations, financial constraints on funding the additional years of “training,” and the effect longer training might have on the relative attractiveness of neurosurgery as a potential career choice. The basic neurosurgical training program of six to seven years is felt to be long enough by most people. There are at least a few programs that are eight years in length; these have built-in features with merit in their own right. However, can one claim that these have to be a part of the general training of a neurosurgeon? Would it be appropriate to extend the length of every program to eight or nine years for the main purpose of providing coverage? How would current residents feel about this change after having signed on for a program that was originally six years long?

Shortening Residency. Conversely, some respondents felt that neurosurgical training should be shortened. There is some merit in this idea. It is arguably possible to train a very good clinical neurosurgeon within a five-year period, which would include one year of fundamental clinical skills and four years of neurosurgery; the four years could include 12 months of neurology, neuroradiology, and neuropathology rotations under the current scheme of requirements. Perhaps the research components and subspecialty training should be considered additional experiences beyond the general training period, to truly reflect an individual’s sincere interest in further pursuits aimed at a focused career goal.

Increasing the Number of Residents. Petitioning the Residency Review Committee and the American Board of Neurological Surgery for more positions may be beneficial for the specialty and the universities, primarily by increasing the sheer number of neurosurgeons in the work force available for covering the hours for which residents formerly were responsible. Also, consider that no trainee can fully capture all of the educational opportunities of any training program and benefit from them, no matter how narrow or expansive the program’s scope may be. There are only so many paths that a resident can pursue, not only in the research arena, but also in the related disciplines of the clinical neurosciences. Training is not exclusively about surgery, although for most of us surgery provides the most satisfaction within the gamut of activities of being a trainee or an attending. However, increasing the number of training positions means that eventually there may be an excess of neurosurgeons for the number of available jobs. Already there is an overabundance of neurosurgeons in some locales and too few in others. How distribution of an increased number of neurosurgeons could be worked out logistically clearly is not an easy task.

Employing Pre-Residency Fellows. Utilizing pre-residency fellows is potentially a reasonable solution. Virtually all of these individuals desire a categorical position in neurosurgery. They are another supply of the potential excess of future neurosurgeons. But what about the ethics of hiring these people, perhaps knowing in advance that their chance of getting into a U.S. program realistically is slim to none? We all know of individuals who, for a variety of reasons, did not get into a neurosurgery program after having spent years performing the functions of a clinical house officer as well as or better than the U.S. senior medical students or categorical neurosurgery residents with whom they worked side by side. Perhaps we should tell them up front that they ought to seek other avenues of career satisfaction. In the end, we may create a situation that will generate much ill will, especially considering that many of these “fellows” are foreign medical doctors. Employing pre-residency fellows might seem to be a ready-made panacea, but perhaps it is not.

Instituting a Night-Float System. Some studies have shown that a night-float system, a system in which designated residents cover night call for a specific time period such as five days per month, is more detrimental to patient care than the traditional system of the same team providing continuous care. That is, a tired team of residents that knows the patient and the nuances of his or her care has been demonstrated to be better for the continuity of care than a rested team that did not know the patient. The residents who are being utilized to cover the night-float system often are sacrificing their time on research or electives which is all about education unrelated to the issues of hospital coverage.

Reducing Research and Electives. Reducing research or elective time and reducing resident involvement in cases sounds convenient, but doing so unquestionably reduces the educational component of the training program. If the problem in many U.S. neurosurgery programs is that there is inadequate education and operative experience, how can we justify taking more of either component away to cover a “teaching” hospital? None of us can feel that doing so is beneficial to either patient care or to our profession in the long term.

Rotating Attendings On Call. Academic attending physicians taking primary call in rotation with residents is something to ponder because it is not entirely unrealistic. It would affect the minority of neurosurgeons who are in full-time academic practices, but it would have no effect on the vast majority of practicing neurosurgeons who cover their patients and the emergency department without a resident buffer.

One must keep in mind that the traditional structure for academic neurosurgery was not designed primarily to create a buffer for the sole interest of the teaching neurosurgeons nor for the exclusive purpose of providing surgical experience so a trainee could try things out while in a “protected” situation. It was conceived as a system of apprenticeship for the trainee to learn the judgment and skills to go on one’s own after completion of a suitable period of time. The very essence of this paradigm now is being put to the test.

Expanding the Role of Post-Residency Fellows. Under these circumstances, the role played by post-residency subspecialty fellows may be expanded to include some of the house staff coverage issues, which by necessity means taking away some of the educational opportunities which might be available to the residents under more traditional circumstances. In might become necessary to create more intracranial subspecialty fellowships if, as many of the study’s respondents believe will happen, intracranial neurosurgical education suffers with the advent of the work hour guidelines.

Employing Physician Extenders Employing PEs was cited as a solution by virtually all of the survey respondents. Realistically, can this be an option for all university hospitals and furthermore, what funds would support this? Should funding come out of the already compromised faculty practice revenue or should teaching hospitals support PEs so that all residents could work reasonable hours (by the way, most people in society don’t think that 80 hours of work per week is reasonable) and faculty neurosurgeons would not have to take primary call? Is it reasonable to assign the degree of responsibility of a mid- or senior-level neurosurgery resident to a mid-level provider? The question here is not whether PEs can and do provide excellent care; they can and they do, particularly in neurosurgery. But is it appropriate to assign that level of responsibility to a mid-level provider and how should this be decided? And is there a ready supply of mid-level providers who are ready to jump into a university practice in neurosurgery?

More Questions than Answers
Many more provocative questions are raised than answered by the implementation of the ACGME’s guidelines. What is academic neurosurgery and what should be the focus of academicians? What are the goals of neurosurgery residency? How long does this process take and to what “acceptable” standard? What is “acceptable” neurosurgical care? How do we go about providing it, while minimizing the necessary casualties and sacrifices that will be made in the transition? In the end, neurosurgical training may be neither about education nor about patient care, but about following a rule that affects specialties differently.

Neurosurgery is a demanding specialty that requires much time and effort to do it justice, just as any other high-stress, performance-driven endeavor. But we cannot ignore the consequences of the work hour restrictions in the hope that an exemption will be granted for neurosurgery. While it is true that neurosurgery is one of the most costly, potentially lucrative, and certainly the highest risk of the medical and surgical specialties, we are going to have to play by the rules like everyone else. The structure of neurosurgical training and, to some extent, neurosurgical practice, now must adapt to accommodate a regulation that neurosurgeons ostensibly had no major role in designing or opposing. And it will be tough, especially in today’s challenging healthcare environment.

Neurosurgery residency in particular (and the medical profession in general) is about service and education, not only education without a service component. Every activity has educational value, even those that are primarily about service, because they can add to the knowledge base for total care delivery. Furthermore, not all trainees (and therefore, not all neurosurgeons) learn and progress at the same rate or arrive at the same destination, as Donlin M. Long, MD, at Johns Hopkins Hospital has demonstrated. Perhaps it is time for us to take a hard look at what we are training people to do, why, and for how long.

A new curriculum, designed to address refined educational objectives within the context of the 80-hour guidelines, is in order, to be tempered by market needs. If we don’t take a proactive stance to determine the future of our own specialty, especially with regard to how and to what extent our future specialists are trained, the rules will be made by others who don’t understand the implications of major sweeping changes, such as this one, which ultimately compromise both service and education.

Dongwoo John Chang, MD, FRCS (C), is director of the Neurosurgery Residency Program and assistant professor of Neurological Surgery at The Ohio State University in Columbus. Susan Bell, RN, MS, CNRN, CNP, is in the Division of Neurological Surgery at The Ohio State University.