The new 80-hour workweek mandated by the Accreditation Council for Graduate Medical Education last July 1 represents a significant reduction in clinical time expended by neurosurgery residents during their course of training. Previously, resident work hours commonly exceeded 110 hours per week and occasionally exceeded 120 hours per week for residents on clinical neurosurgery services.
The Council of State Neurosurgical Societies’ study conducted by Richard D. Fessler, MD, and colleagues gauges the opinions of both program directors and residents regarding the new work hour restrictions. Both essentially agree that under the new mandate: the provision of appropriate continuity of patient care will be hampered; residents will not attain enough experience performing the broad spectrum of neurosurgical procedures; and the educational process will be degraded by the inability of residents to follow patients throughout their episode of care.
Interpreting Surveys? Use Care
One must always exercise care in the interpretation of surveys. In this case, one might inquire: Does the survey ask the right questions? What truly are the questions at hand? Do we want to know whether or not the change represented by the new mandate angers us or makes us uncomfortable? Or, do we want to know whether or not there indeed were significant problems with the “old system? If the latter question is answered affirmatively, as I believe it would be, one might want to know if the “new system” represents at least a change in the right direction.
The CSNS study answered the question pertaining to how neurosurgeons feel about the workweek restrictions. It indeed angers neurosurgeons to have new rules and regulations thrust upon us; and with change there always is a period of discomfort. However, a careful, thoughtful and methodical introspective analysis might yield markedly different results. Isn’t it true that residents were commonly used as agents of service for both the faculty and the hospital? Late rounds at the faculty member’s convenience, scrubbing in on or performing “boring” cases of questionable educational value, and performing “scut work” that hospital employees could readily perform: Each represents an abuse of the resident and his or her status as a neurosurgical trainee.
The “old system” wasn’t as educationally oriented as some would like to think it was. The “new system” possibly could be better, particularly if neurosurgeons work to modify and improve it. However the 80-hour workweek may not be long enough, and most programs should apply for the 10 percent extension. Eighty-eight hours, particularly if averaged over four weeks, should be enough time to train residents in a humane manner if the training occurs in an enriched environment.
Training in an Enriched Environment
An enriched environment requires that program directors and faculty become more involved with the process of education. Rotations and conferences must be modified. Clinics and operating times need to be scheduled, at least in large part, on the basis of their educational impact rather than on the basis of their convenience for the faculty. Senior faculty cannot and should not expect “senior resident coverage” for uncomplicated surgical procedures simply because they are “senior faculty.” Cases should be distributed on the basis of their educational value to each resident and on the basis of the provision of quality patient care. The hospital must assume a greater portion of the burden of routine inpatient and outpatient ancillary care, such as blood drawing and patient transport. Some rotations perhaps could be eliminated. Smaller training programs may no longer have the luxury of rotating residents through multiple hospitals.
When the aforementioned adjustments are accomplished, a quality training program most certainly can be achieved in a workweek of 80 to 88 hours. The burden for its success, however, lies with the faculty members and the hospital in which they practice, as well as with the residents themselves. The residents must be allowed, and in fact encouraged, to actively participate in this process.
Is the new mandate totally appropriate? Residents are, indeed, sleeping less during educational conferences, reading and studying more, and demonstrating a greater knowledge base on rounds, in the clinics, in the operating rooms, and in conferences. Has their surgical and outpatient clinical experience been improved by the mandate? This depends on the commitment of the faculty and the institution to the educational process.
Room for Improvement
There most certainly is room for improvement in both the mandate and in neurosurgery’s implementation of it. I suggest that neurosurgeons strive to improve the existing mandate in a proactive manner, rather than resist, defile and defame it. If an average of 80 to 88 hours per week is enough time to acquire a good education, then the main problem with the new mandate centers on the rigid nature of the work hour limitations. Neurosurgery indeed is not shift work. Clinical neuropathological processes are not predictable. The demand they place on caregivers also is unpredictable. The ebb and flow of the workload thus is significant. In this regard, the guideline of 10 hours off duty between 24-hour shifts on duty perhaps requires modification to provide the neurosurgical resident the latitude to care for patients in a “real life” environment in which the normal and natural ebb and flow of work occurs.
It is only with these minor modifications of the existing mandate in place that neurosurgery residents truly will learn the craft of neurosurgery in an enriched and humane environment and accomplish more within a restricted timeframe than in days gone by. Then, and only then, the characteristics that both the specialty and society want to see in a neurosurgeon-knowledge, skill, professionalism, responsibility, and an unflagging commitment to the patient-will not be lost.
Edward C. Benzel, MD, is chairman of the Cleveland Clinic Spine Institute, vice chairman of the Department of Neurosurgery, and director of the Neurosurgery Residency Program, at the Cleveland Clinic Foundation, Cleveland, Ohio.