Survey Documents Concerns for Tomorrow’s Neurosurgical Workforce
Most neurosurgeons are available to referring physicians and patients seven days per week, 24 hours per day. Many of us believe that our training prepared us for this through years of intense, often exhausting training. The recently mandated Accreditation Council for Graduate Medical Education (ACGME) training guidelines has altered this approach.
Beginning last July 1, all core and subspecialty training programs in the United States are required by the ACGME to include in their training guidelines language strictly delineating resident duty hours, call requirements, and days off. The guidelines include an 80-hour workweek; restriction of in-house call to a maximum of every third night; and limitation of each work shift to 24 consecutive hours, followed by a minimum of 10 hours off between these shifts. Each resident has one day free of responsibilities for every seven days of work.
Each neurosurgical program has coped with the guidelines in its own way, putting in place schedules that ensure adequate time off for trainees, and hiring ancillary medical professionals (physician assistants, nurse practitioners, and moonlighters) to bridge the gap in coverage. According to the ACGME, preliminary data suggests that residents in training overwhelmingly support the new training hours and report increased satisfaction.
In an effort to gauge how the ACGME guidelines have specifically affected neurosurgical training programs, the Council of State Neurosurgical Societies surveyed program directors and residents last summer.
The CSNS Survey
Nine multiple choice and open-ended questions were sent by e-mail to 93 program directors and more than 600 residents in training. The survey was distributed in July, August and September. Respondents were removed from the listserve as their surveys arrived. Nonresponders received the survey up to three times. Response rates were 45 percent and 23 percent for program directors and residents, respectively.
More than 90 percent of neurosurgical programs represented by a survey response had initiated measures to comply with the ACGME guidelines before or on July 1. Not surprisingly, there was strong agreement between the residents and program directors on several issues. The majority of residents and program directors felt that their programs had experienced a negative impact from the ACGME guidelines. Patient continuity of care was the most significant issue.
More than two-thirds of program directors and residents felt that the ACGME guidelines had affected continuity of care. Ninety percent of those who noted a change felt that there was a negative effect on patient care. Interestingly, most of the program respondents who noted no significant change in continuity were involved in programs that trained more than two residents per year or that did not maintain coverage of a level one trauma center. Residents and program directors noted that patient care suffered from the intermittent absence of the chief and senior residents. In addition, they felt that patient care was negatively influenced when the on-call resident had to leave the hospital the next morning. Details concerning the neurological exam and plan of treatment were often “lost in translation” and the call resident was unable to follow his or her patient to the operating room or follow the progression of the disease.
Program directors commented on a significant change in the daily knowledge of the residents relative to the patients and an emerging “shift mentality” in the resident corps. While most program directors believed that their patients were well cared for, they noted an increasing reliance on staff physicians and ancillary professionals to maintain continuity of care.
Chief and senior residents were most vociferous in their comments, many noting that their “chief year has been ruined” by limited duty hours and that their interaction with the junior residents in the operating room has diminished. Several chief and senior residents complained of the ethical dilemma caused by limited duty hours relative to their patients and their perceived training needs. The chief and senior residents often are charged with “maintaining compliance” and bear the brunt of the additional workload caused by the limited availability of junior residents post-call. Many noted that they, themselves, were not in compliance, but that the remaining residents were. This difficulty in maintaining compliance was an issue primarily at smaller, high-volume programs. Program directors appear to be unaware of this, as nearly 90 percent believe their programs are in compliance versus less than 80 percent of residents who believe this to be true.
Training Programs in Flux It is clear that neurosurgical training programs are in a state of flux on the heels of the new work rules and have not yet reached equilibrium. Unfortunately for neurosurgery, the lessons learned in New York State over the past 10 years do not appear to have been taken into account by the ACGME relative to surgical training programs. In New York, junior residents report greater satisfaction than senior residents due to limited work hours, yet senior residents note a decline in the quality of their training due to limited work hours. Similar findings appeared in the current survey, with a shift of nonoperative responsibilities to the senior residents as junior residents left the hospital post-call.
While it may be reasonable to adjust resident work hours, it is apparent that “one size fits all” does not meet the needs of neurosurgical training programs. Compared to other specialties, neurosurgical programs are small, but they vary widely among themselves in number of trainees and clinical volume. Major changes in training, as mandated by the ACGME, will have far-ranging effects in a small, labor-intensive specialty such as neurosurgery. It is clear that neurosurgical program directors and residents are unhappy with the initial effects on their training programs. However, in spite of what we perceive to be the current limitations imposed on neurosurgical training programs, we must continue to provide appropriate cases, teaching, and mentoring to our future neurosurgeons.
Richard D. Fessler, MD, is associate clinical professor in the Departments of Neurosurgery and Radiology at Wayne State University School of Medicine, Detroit, Mich.