Neurosurgery Residents Oppose Duty Hour Limitations

Nancy A. Melville

January 17, 2012

January 17, 2012 — Neurosurgery residents strongly oppose new duty hour limitations imposed by the Accreditation Council for Graduate Medical Education (ACGME), and most feel that the specialty as a whole should not be subject to the same duty hour restrictions as other specialties, a survey suggests.

The survey showed that 72% of residents said they felt that new duty hour standards that began in July 2011 would have a negative or strongly negative effect on their residency training, and more than a third (36%) of residents reported regularly or occasionally violating the ACGME's 80 hours/week rule.

The survey results were published in the December 2011 issue of Neurosurgery.

Surveys were sent to all of the neurosurgery training programs (101 programs) in the United States and Puerto Rico, and the responses reflect the opinions of 377 residents (34%) who returned them — about a third of the country's neurosurgery residents.

Sweeping Restrictions

Sweeping duty hour restrictions were put in place by the ACGME in 2003 in response to concerns about medical errors and auto accidents stemming from resident fatigue after working long shifts.

The restrictions were updated in July in the wake of a 2008 report from the Institute of Medicine that included recommendations for new additional restrictions from the Committee on Optimizing Graduate Medical Trainee Hours and Work Schedules to Improve Patient Safety.

Among the new rules was a stipulation of a 16-hour shift limitation for postgraduate year 1 residents. As many as 83% of the survey respondents said they disagreed with the new rule, a sentiment that has been voiced in previous surveys.

"When all the duty hour changes are considered, the 16-hour regulation appears to stand out as the most controversial, particularly given the paucity of scientific support and the predominantly negative attitudes among program directors and residents," the authors write.

At the crux of the opposition to duty-hour restrictions in general is the issue of neurosurgery patients' need for a complex and advanced level of care that must be sustained over the potentially long course of an episode or surgery.

The concern is that this continuity of care for patients is compromised, as is essential training time, when residents need to adhere to restrictions on the duration of their shifts, said lead author Kyle M. Fargen, MD, MPH, from the University of Florida Department of Neurosurgery in Gainesville.

"Neurosurgery residents must care for large numbers of patients, many of whom are critically ill, and must learn to operate in long, complex cases from start to finish," he told Medscape Medical News.

"Most residents barely make it under the 80-hour limit on a week-to-week basis. Frequently, residents are forced away from important experiences, like finishing a surgery, addressing their patient needs, or other educational patient encounters, so that they stay under 80 hours for the week."

Interestingly, the strong opposition to the new rules was voiced despite the fact that 31 residents (8%) reported being involved in a motor vehicle collision or life-threatening event, and 20 (6%) reported having made a medical error resulting in patient harm after an extended shift.

Although such incidents are what prompted the ACGME restrictions in the first place, the concern that duty hour restrictions pose an even greater risk to patients is one that is shared by the specialty in general, according to Robert E. Harbaugh, MD, director of the Penn State Institute of the Neurosciences and distinguished professor and chair of the Penn State University Department of Neurosurgery in Hershey.

"Whenever you turn care over to another provider, no matter how careful you are about trying to document everything that's happened, there's a chance that some important piece of information is going to be missed, and that's a concern in terms of patient safety," he told Medscape Medical News.

"There has always been the expectation of dedication to the patient until a crisis has passed and they have been stabilized, and you don't want to just punch the clock and go home because your shift is up and turn that over to someone who has to catch up on everything and hasn't been through the rest of the episode with the patient."

"We would hate to see a shift-work approach to patient care become the norm," he emphasized.

Substantial Oversight

A key issue that should not be overlooked is the fact that residents, particularly those in their early years, are never without substantial oversight, Dr. Harbaugh noted.

"In almost every neurosurgery program that I'm aware of, there are multiple residents available for patient care, and first-year residents aren't out there unsupported by people with more experience.

"They have more senior residents on service with them at the same time, and the faculty are almost always immediately available as well, via telephone, and with new technology we can even view images and video from home."

The survey was conducted before the implementation of the new rules, but Dr. Fargen said a new survey is under way to assess how or if residents' views have changed under the new policies.

One thing that likely has not changed, however, is the deep-seated view of neurosurgery as a highly specialized field that requires unique levels of commitment and tenacity, and perhaps unique rules to follow suit, he said.

"Residents choose to pursue neurosurgery because it is difficult and complex, yet highly rewarding," Dr. Fargen said. "They are aware when they choose to follow this path that they are committing a large portion of their life — 6 or 7 years — to a field that requires intense focus, long hours, significant personal sacrifice, and an ability to handle high-pressure, high-stress situations.

"Many neurosurgery residents take pride in these responsibilities, and some indicate that mastery of the complex skill sets required of independent neurosurgeons requires a commitment beyond that of physicians in other specialties."

Dr. Fargen and Dr. Harbaugh have disclosed no relevant financial relationships.

Neurosurgery. 2011;69:1162-1170. Full text