Neurosurgery Associations Push Back on IOM Resident Work-Hour Report

Susan Jeffrey

December 09, 2008

December 9, 2008 (updated December 11 with commentary) — Professional neurosurgery associations are raising "serious concerns" about new recommendations from the Institute of Medicine (IOM), released December 2, advocating further restrictions to resident work hours.

In a joint statement, the American Association of Neurological Surgeons (AANS), the American Board of Neurosurgery (ABNS), the Congress of Neurological Surgeons (CNS), and the Society of Neurological Surgeons (Senior Society) urged the Accreditation Council for Graduate Medical Education (ACGME) to carry out additional research on the current work-hour rules before any further changes to existing policy are made.

The authors of the IOM report, however, respond in a statement to Medscape Neurology & Neurosurgery that patient safety was their first priority and that they stand by their recommendations.

Significant Harm?

In the joint release, the neurosurgery organizations point out that the current ACGME rules were established in 2003 to limit the work hours of residents, and the neurosurgery community "embraced" those rules, the statement says, resulting in changes that "substantially modified the way residents are trained." Further restrictions to duty, though, would have the potential "to significantly harm patients and increase healthcare costs," the joint release adds.

"The IOM committee, in making these recommendations, has failed to adequately consider the key patient-safety issues — the considerable risks associated with too many patient handoffs and lack of continuity of care in complex neurosurgical disease or injury cases," said AANS president James R. Bean, MD, in the statement.

Additional restrictions would also create a generation of surgeons with greatly reduced surgical experience and expertise, adds Sean Grady, MD, from the University of Pennsylvania, in Philadelphia, current ABNS chair. "Unless the residency training period is extended considerably, residents in neurosurgery will receive 25% to 50% less training than residents received prior to 2003," Dr. Grady said. "One could reasonably ask whether any patient would choose to be treated by a neurosurgeon who receives half the training of today's practitioners."

"Given that the IOM committee did not include a single practicing representative from a surgical discipline, we are not entirely surprised by the recommendations in this report," added Robert E. Harbaugh, MD, from Pennsylvania State University and Milton S. Hershey Medical Center, in Hershey, also in the release. "It is shockingly simplistic to apply a one-size-fits-all approach to residency training, and the IOM report appears to gloss over the significant differences among the various specialties, which make certain per-shift and other duty-hour restrictions feasible in some training programs but not others."

The upshot would be a need for more faculty and longer residency training to gain requisite experience, the statement adds. "There are only approximately 3300 actively practicing neurosurgeons serving over 5000 hospitals in the United States, and any further restrictions on neurosurgical workforce will certainly reduce patient access to neurosurgical care," said H. Hunt Batjer, MD, from Northwestern University, in Chicago, Illinois, immediate past chair of the ABNS.

Fatigue and Medical Errors

The IOM report, entitled "Resident duty hours: enhancing sleep, supervision and safety," was funded by the US Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ). It was published online December 2 and reported by Medscape at that time.

The IOM committee carried out a 15-month study looking at the associations between residents' work schedules, their performance, and the quality of care provided. They found that residents suffering acute and chronic fatigue were more likely to make errors. Their report recommended strategies to reduce these errors and improve patient safety by reducing residents' duty hours, increasing their sleep hours, and increasing supervision of work-hour limits.

"The [IOM] study provides the clear evidence to prove what we have long believed is true — fatigue increases the chance for human error," AHRQ director Carolyn M. Clancy, MD, said in a news release. "Most important, this report provides solid recommendations that can improve patient safety as well as increase the quality of the resident training experience."

Current rules of the ACGME permit a maximum 30-hour shift for residents, including direct patient care for 24 hours, and training or transition activities for the remaining 6 hours, as well as a maximum 80-hour workweek. Among other restrictions, the new IOM report recommends that residents who complete a 30-hour shift may treat patients for only up to 16 hours, followed by a 5-hour protected sleep period between 10 pm and 8 am, during which time patient care would be managed by other nonsleeping residents or additional staff members.

The IOM has issued no official response to the neurosurgery societies' statement, a spokesperson at the IOM told Medscape Neurology & Neurosurgery.

Report Authors Respond

However, contacted for comment, Michael M.E. Johns, MD, chancellor of Emory University, in Atlanta, Georgia, and chair of the IOM Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety, responded on behalf of the authors of the report. He pointed out that, in 2007, at the request of Congress, he and his colleagues were charged with evaluating the evidence on the topic and recommending ways to improve conditions for patient and resident safety during training.

"The primary goal for the committee, as for any physician, was patient safety," Dr. Johns said in a statement to Medscape Neurology & Neurosurgery. "We were concerned with the safety of future patients as well as the care of current ones. Hence, the education of residents and their need for experience to become capable, independent practitioners was also critical."

The committee has received a lot of feedback on the report, he noted, some of which say it went too far in limiting duty hours, some suggesting it did not go far enough, and some agreeing that it struck the right balance between patient safety and the education of residents. "As discussion of the report continues among all involved parties, I hope that the full range of recommendations will be considered, since it is the interplay of supervision, improved conditions for work and education, improved handoffs, changes in the culture of safety, and monitoring of the impact of all the changes that will make the new limits feasible and promote the committee's goal of safety in the short and long term."

The committee was charged with making recommendations for all residents across a wide range of specialties, and it "fully recognizes" that different specialties vary in their specific needs, Dr. Johns writes. "While we heard testimony from a range of specialties about their unique circumstances, the lack of solid data and evidence of their unique characteristics made it impossible to tailor recommendations to particular specialties."

The committee did hear from several groups representing surgeons, including neurosurgeons, who anticipated negative consequences from further cuts to the 80-hour-per-week maximum, he notes, but the committee concluded that the maximum hours allowed per week should remain at 80, averaged over 4 weeks, leaving some flexibility for different specialties to schedule up to this maximum. Although it found no national evidence on the proportion of surgeries that last 2, 4, or 18 or more hours, the recommendations permit exceptions to the duty-hour limits to accommodate the rare long surgeries where the presence of residents is essential for patient safety or a unique learning experience, Dr. Johns adds. "However, we believe that such cases should be exceptions, not the norm."

The recommendation to limit continuous work hours to 16 hours without a break or 30 hours with 5 of uninterrupted rest is grounded in the science of sleep and human performance that has shown that performance can be impaired after 16 or more hours of wakefulness, he writes. "Residents in all specialties are human beings."

However, in his view, the discussion of duty-hour limits "is missing a broader, important point," Dr. Johns writes. "Duty hours by themselves are not a guarantee of patient safety. Inadequate supervision of doctors in training and excessive workloads also increase the chances of medical errors." The report includes recommendations on these aspects of care that are "essential accompaniments to our recommendations on duty hours."

Finally, he notes, "the report also underscores that a resident cannot and should not serve as the sole provider and caretaker of a patient." A team approach should become more common and be better managed to ensure the continuity of care. "Handoffs of patients are inevitable, but the current approach to handoffs, which is often rushed, inconsistent, and incomplete and permits communications errors, is not inevitable. Nor is it an excuse to maintain long duty shifts.

"We provide an extensive review of the training, duty hours, and safety issues and offer a comprehensive strategy to allow residents to develop competencies within an intensive but reasonable framework," Dr. Johns concludes. "But more important than the various needs of individual specialty residency programs is the common goal they share of responsibly providing safe and quality care to patients while training our next generation of physicians."

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