Listening to colleagues across the country discuss their perceptions of the post-July 2003 environment, I hear hauntingly familiar refrains, the same ones that echoed throughout New York more than 10 years ago when the state began to enforce its own resident work hour restrictions. Because academicians, including neurosurgeons, learned little from the New York experience, many will be doomed to repeat the failures of others, perhaps at the expense of resident satisfaction, faculty attrition, and sadly, quality of care for our patients.
Perhaps the most common refrain is that the new resident work hour restrictions, which were mandated nationally by the Accreditation Council for Graduate Medical Education, will debase the profession of medicine resulting in a “shift-worker mentality” attended by failure to commit to the best care for our patients. Anecdotes abound of residents leaving in the middle of cardiac arrest codes, showing up late for rounds because they were entitled to their required time off, and similar behaviors. But these remain anecdotes, less valid scientifically than case reports, and the new reality has yet to be assessed.
It is likely that the full impact of the ACGME resident work hour restrictions will not be understood for a generation, when the residents training under this new system gain seniority and assume roles as program directors and chairs of departments. At this time, two years into national implementation of the 80-hour resident workweek, a brief look at the history of this reform and at how the future success or failure of this change will be assessed may be instructive.
Into the Past
Resident work hour restrictions, arguably medical education’s most sweeping reform in this century, evolved following the death of Libby Zion at a New York Hospital in March 1984. A junior resident admitted her with fever, chills and dehydration; by the next morning, she had died. While the exact cause of her death has never been determined, a New York grand jury investigation in 1986 found that the death was related to 36-hour sleepless resident shifts and inadequate supervision by attending physicians.
Sidney Zion, Libby Zion’s father and also a newspaper columnist and attorney, sued New York Hospital and the physicians for malpractice. More than the malpractice case, he began a crusade against the system, targeting the long resident work hours and poor supervision that he felt had contributed to his daughter’s wrongful death.
The publicity surrounding this case led the New York Health Commissioner in 1987 to form an ad hoc advisory committee chaired by Bertrand Bell, a professor of medicine at Albert Einstein College of Medicine. The committee’s strong recommendation to restrict resident work hours led to New York State health code legislation enacted July 1, 1989, commonly known as the 405 Regulations. Sidney Zion, however, continued to campaign, claiming that many hospitals were wantonly ignoring the code. In 1998, stiff hospital penalties were added. Initial violations could be fined up to $6,000 per violation with follow-up violations escalating to $25,000 and then $50,000.
While New York hospitals were struggling with the 405 Regulations, the push to implement national work hour restrictions began. In 2002 the ACGME announced its intention to impose national duty hour regulations effective July 1, 2003.
A Look at the Present
Assessment of the effect of the 80-hour resident workweek within much of surgery has emphasized the loss of surgical case volume and the dilution of the surgical training experience (3,11,13). The two studies published in this issue of the AANS Bulletin demonstrate the reduced number of cases in which neurosurgical residents are participating following implementation of the work hour restrictions. Unfortunately, little is known about how many procedures a resident must do to achieve competence or to attain the necessary balance of didactics, patient care, and technical training. Clearly individual residents follow very different learning curves. Surgical simulators, which increasingly are being used for both training and assessment of technical skills (6,7,9,15), may at least partially fill the gap in operative experience opened by the restrictions and also provide additional exposure to particular techniques. Some have even suggested applying the model of flight training to resident education, requiring residents to have simulation experience before they are awarded any patient responsibility (12).
While volume of surgical cases always will be an important factor in technical training, many other factors may also be crucial to achieving technical proficiency. At the same time, fatigue, the technical and supervisory skill of the attending surgeon and the resident’s own preparation all may affect the ability to learn surgical technique. Increasing evidence has emerged about the effect of fatigue on medical errors (4,16), resident safety (1), and resident burnout (14). The impact of this research on the public is far greater than the multitude of more descriptive studies on attitudes and perceptions. To date, few studies have even tried to assess the impact of resident work hour restrictions on quality of patient care (2). Several studies have raised the concern of continuity of care but without clear evidence that it has been compromised by the restrictions (10,17). Just one study has addressed the issue of patient satisfaction and physician fatigue, finding that rested residents received consistently higher ratings from patients (8).
Attention also has been given to resident attitudes and the increasing time and responsibility on attending physicians (5,14,20). At least one study failed to document increased faculty hours (19). Most studies of resident attitudes and perceptions are most notable for the differences expressed by senior and junior residents, with junior residents generally more likely to view the 80-hour workweek positively (10,17,18). This may be a reflection of the longer hours junior residents typically work or of a wider acceptance of the new paradigm of training permeating medical schools. This dichotomy of attitudes supports the idea that assessing the full impact of these changes may take many years, perhaps a “training generation.”
A Note on Cost To date, little public consideration has been given to the cost of this mandate. When penalties were instituted for violation of New York’s 405 Regulations, the state provided significant funding to hospitals to balance the new costs. Unfortunately, over time these added monies were withdrawn, though the higher costs remain in place and new funding was not appropriated with the institution of the national ACGME regulations.
At my own institution, three full-time nurse practitioners were hired in the neurosurgery department at a cost of $375,000 per year to cover 120 hours of “lost” resident time, and conference time for neurosurgery residents declined by 25 percent. To compensate for its own loss of 120 hours of resident time, the orthopedics department hired five physician extenders at an annual cost of $520,000 and recalled two “away” residents to the primary institution. The hospital also hired a compliance officer, initially half time, then full time at a cost of $80,000 per year, as well as ancillary staff at an estimated cost of $250,000 per year. These hospital-wide costs were shared by the neurosurgery and orthopedics departments, bringing the annual cost of the work hour restrictions for just two surgical specialties at one hospital to nearly $1 million.
Implementation of the work hour restrictions also has coincided with that of several other unfunded mandates: maintenance of certification, ACGME Core Competency Assessments, and the Health Insurance Portability and Accountability Act — all hitting at a time when most medical institutions have little operating surplus. While few in organized medicine argue with the concepts of maintaining patient confidentiality, error reduction, provision of quality care, and developing sound resident education and evaluation, the accompanying cost makes embracing these programs more difficult. At least some of the funding for these mandates has negatively impacted physician salaries. How this will impact retention and recruitment of faculty into academic programs remains to be seen.
The Prospective Reality
In the future, will expectation of a more reasonable workweek make entering medical school more appealing to a wider range of applicants? Will traditionally time-demanding subspecialties like neurosurgery become more appealing by leveling the time component of the playing field? Medical students entering new residencies in 2006 will have started medical school knowing of the 80-hour restriction. Soon after, we can more fully understand how the new landscape will be shaped.
It has always been surprising to me that once neurosurgeons leave residency, they have the magical ability not only to forget the physical and mental stress of those years but to look back on them as the best years of their lives! Many who then enter academic medicine find it difficult to fathom another system that could successfully train competent neurosurgeons. However, rather than resisting the restrictions that already are in place, perhaps neurosurgery would be better served by participating in a concerted effort to assess the success or failure of this major paradigm shift on the quality of resident education and patient care. By understanding the critical factors that contribute to successful resident education and technical training, including work schedules, we will meet the goals of medical education.
Deborah L. Benzil, MD, is associate professor at New York Medical College, Valhalla, N.Y., and a neurosurgeon at Westchester Spine and Brain Surgery PLLC, Hartsdale, N.Y.
Avinash Mohan, MD, a resident at New York Medical College, contributed to this article.
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